An older adult client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high-fiber foods to the client that the healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods?

Use background music to promote relaxation.

Turn on overhead lights while giving instructions.

Stand behind the client to avoid intimidation.

Provide handouts written at a 12th grade reading level.

Answer and Explanation

The Correct Answer is D

A. Background music may be distracting rather than helpful during teaching.

B.   Adequate lighting is crucial for older adults to clearly see and read instructional materials. However, overhead lights may be distracting and disorienting for an older adult.
C.   Standing behind the client might actually increase feelings of intimidation or discomfort. It's better to face the client to facilitate communication.
D.   Providing handouts written at a 12th grade reading level ensures that the information is accessible and understandable for the majority of adults.

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Correct Answer is D

Explanation

A. Involving another nurse might not necessarily address the client's guarded and suspicious behavior.
B. Documenting the behavior is important for the client's records, but it doesn't address the immediate need for assessment.
C. Postponing the interview might not resolve the client's guarded behavior and could delay necessary assessment.
D. Attempting to ask the client simple questions allows for a non-threatening approach and might gradually build rapport, encouraging the client to engage in conversation.

A. Activated partial thromboplastin time (aPTT) is 2 times the control value. B. S3 heart sounds are present with auscultation. C. Cardiac tracing shows 1.2 mm wide Q waves half the height of the complex. D. Guaiac test of the stools is positive.

Correct Answer is A

Explanation

A. An aPTT that is 2 times the control value indicates that the heparin is effectively anticoagulating the blood, which is a desired outcome in managing MI to prevent clot formation.
B. S3 heart sounds can indicate heart failure and are not a sign of a satisfactory response to MI treatment.
C. Wide Q waves indicate a previous infarction but do not reflect the immediate effectiveness of the treatment.
D. A positive guaiac test indicates gastrointestinal bleeding, which is a potential complication rather than a satisfactory response.

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An older adult client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high-fiber foods to the client that the healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

Correct Answer is D

Explanation

A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response?

Correct Answer is A

Explanation

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