While taking a history on an older adult male client, his wife reports that he is having increasing periods of short-term memory loss and he occasionally gets confused. How should the nurse proceed with an assessment of the client's sensory system?

Explain the tests to the wife so she can interpret them for her husband.

Assess the client's ability to follow directions before proceeding with the exam.

Defer this part of the exam because the results are likely to be invalid.

Perform the tests because the client's mental status does not affect sensory status.

Answer and Explanation

The Correct Answer is B

A. Explain the tests to the wife so she can interpret them for her husband: While involving family members can be helpful in some situations, it is essential for the client to actively participate in sensory assessments. Having the wife interpret the tests may not give an accurate representation of the client’s sensory capabilities.

B. Assess the client's ability to follow directions before proceeding with the exam: Accurate sensory testing relies on the client's ability to understand and follow instructions, as well as to accurately report sensations. It is important to first evaluate whether the client can understand and follow instructions, as cognitive or memory issues may affect their ability to engage in the sensory exam. This step ensures that the assessment results are valid and reflective of the client’s true sensory function.

C. Defer this part of the exam because the results are likely to be invalid: While cognitive decline can impact the reliability of the exam, it is essential to assess the client's ability to participate and follow instructions before determining whether the sensory exam can be conducted properly. Deferring the exam without evaluation of comprehension is inappropriate.

D. Perform the tests because the client's mental status does not affect sensory status: While mental status may not directly affect the sensory pathways, the ability to follow directions and focus on the exam does influence the accuracy of the assessment. Proceeding without assessing the client's ability to participate could result in inaccurate findings.

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Correct Answer is B

Explanation

A. Palpating in the wrong abdominal quadrant: The gallbladder is typically located in the right upper quadrant beneath the liver, so palpating outside this area would be incorrect. However, the question specifies the nurse is palpating below the liver margin at the lateral border of the rectus muscle, which is the correct anatomical location.

B. The gallbladder is normal: A healthy gallbladder is not usually palpable. It is generally only felt when inflamed or enlarged, such as in cholecystitis. Therefore, not being able to palpate the gallbladder is most often a sign of normalcy rather than a problem.

C. Deeper palpation technique is needed: While obesity may make palpation more difficult, even with deeper technique, a non-enlarged gallbladder remains non-palpable in most individuals. Deeper palpation is not typically indicated unless there’s suspicion of pathology.

D. The client is too obese: Although obesity can hinder palpation of abdominal organs, the inability to feel the gallbladder is most likely due to its normal size and condition rather than body habitus alone. In both obese and non-obese clients, a non-distended gallbladder is generally not palpable.

A. "Refrain from eating or drinking for at least thirty minutes." B. "Lie in a prone position with slightly flexed knees." C. "Empty your bladder just prior to the examination." D. "Exhale slowly through your mouth then hold your breath."

Correct Answer is C

Explanation

A. "Refrain from eating or drinking for at least thirty minutes. There is no strict requirement for fasting before a standard abdominal exam unless it's for a diagnostic procedure like an ultrasound. Eating or drinking within 30 minutes does not typically interfere with the physical assessment of the abdomen.

B. "Lie in a prone position with slightly flexed knees." The prone position (lying face down) is not appropriate for an abdominal exam. The correct position is supine (lying on the back) with knees slightly flexed to help relax abdominal muscles and enhance comfort during palpation.

C. "Empty your bladder just prior to the examination." An empty bladder helps reduce discomfort and allows for more accurate palpation and assessment of abdominal organs. A full bladder can distort findings and interfere with the nurse’s ability to assess lower abdominal structures properly.

D. "Exhale slowly through your mouth then hold your breath." While breathing techniques may be used during specific parts of the assessment (e.g., liver palpation), this instruction is not the first or primary preparation step. Emptying the bladder takes priority to ensure accuracy and comfort.

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While taking a history on an older adult male client, his wife reports that he is having increasing periods of short-term memory loss and he occasionally gets confused. How should the nurse proceed with an assessment of the client's sensory system?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

Correct Answer is B

Explanation

When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

Correct Answer is C

Explanation

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