Which strategy can the nurse use to effectively approach the older adult client during the health history?

Keep the pace of the history moving forward to reduce time.

Limit the use of brief screening tools

Limit open-ended questions.

Have the room well-lit with minimal background noise.

Answer and Explanation

The Correct Answer is D

(A) Keep the pace of the history moving forward to reduce time: While it's important to be efficient, rushing through the health history can compromise the quality of the information gathered. Older adults may need more time to recall details and respond thoughtfully. Ensuring a thorough and patient approach is essential for obtaining accurate and comprehensive information.
(B) Limit the use of brief screening tools: Brief screening tools can be valuable for identifying specific health issues quickly and efficiently. Limiting their use might lead to missing important information or failing to detect underlying conditions. Using appropriate screening tools helps in capturing relevant data and providing a better overall assessment.
(C) Limit open-ended questions: Open-ended questions are crucial in obtaining detailed and descriptive responses from older adults. Limiting their use could hinder the ability to understand the client’s complete health history and concerns. These questions encourage clients to elaborate on their experiences and provide more nuanced information.
(D) Have the room well-lit with minimal background noise: A well-lit room with minimal background noise creates an environment conducive to effective communication. Older adults might have impaired vision or hearing, so ensuring good lighting and reducing distractions helps them focus and respond more accurately. This strategy enhances the accuracy of the health history and facilitates better interaction between the nurse and client.

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Correct Answer is C

Explanation

A. Obtunded: Obtunded describes a state where a person has reduced alertness and is difficult to arouse but can respond to stimuli, such as verbal commands or physical touch. The client’s eyes remain closed and they are unresponsive to all stimuli, which is more severe than obtunded.
B. Stupor: Stupor is a condition where a person is in a near-unconscious state and responds only to vigorous or painful stimuli. Although the client is unresponsive to all stimuli, stupor usually involves some minimal response to pain or other strong stimuli, which doesn’t match the complete unresponsiveness described.
C. Coma: A coma is a profound state of unconsciousness where a person is unresponsive to all stimuli, including verbal, visual, and painful stimuli, and their eyes remain closed. This description matches the client’s condition of being unresponsive and with closed eyes.
D. Lethargy: Lethargy is characterized by excessive drowsiness or a reduced level of consciousness where the individual can be aroused with minimal effort. This state does not accurately describe a client who is unresponsive to all stimuli and whose eyes remain closed.

A. Sigmoid colon B. Appendix C. Right Fallopian Tube D. Ascending Colon E. Right kidney F. Right side of the prostate

Correct Answer is ["B","C","D"]

Explanation

A) Sigmoid colon: The sigmoid colon is located in the Left Lower Quadrant (LLQ) of the abdomen. Therefore, a bulging area in the Right Lower Quadrant (RLQ) would not be associated with the sigmoid colon.
B) Appendix: The appendix is located in the Right Lower Quadrant and is a common site for abdominal masses, especially in cases of appendicitis. A bulging area in the RLQ could very well be related to issues with the appendix.
C) Right Fallopian Tube: The right fallopian tube is located in the RLQ of the abdomen. Conditions affecting the fallopian tube, such as an ectopic pregnancy or tubo-ovarian abscess, could cause a bulging area in this quadrant.
D) Ascending Colon: The ascending colon is also situated in the RLQ. A mass or bulge in this area could be related to conditions affecting the ascending colon, such as colonic obstruction or tumors.
E) Right kidney: The right kidney is located in the upper abdominal area and is more likely to cause tenderness or discomfort in the upper quadrants rather than a bulging mass in the RLQ.
F) Right side of the prostate: The prostate gland is located in the pelvic area, specifically in the male pelvis, and would not typically be associated with a bulging mass in the RLQ of a female patient.

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Which strategy can the nurse use to effectively approach the older adult client during the health history?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Assessment of the client reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?

Correct Answer is C

Explanation

During an abdominal examination, the nurse palpates a bulging area in the Right Lower Quadrant of a female patient. The nurse suspects that this mass could be associated with which of the following organs? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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