Practice Quiz

NCLEX-RN

Category - Reduction of Risk

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The nurse performs a routine examination on a 79-year-old client. The client had a recent hip replacement surgery. The nurse observes that the client seems more quiet and lethargic than the usual. The nurse’s initial action is to:
  1. Engage her in a fun conversation.
  2. Notify the physician.
  3. Verify her observation with other nurses.
  4. Check the last dose of pain medication.
Explanation
Answer: D - Lethargy may be an indicator of pain in the elderly. Initially, the nurse should assess if the client is in pain. It is common in elderly clients to have lesser perception of pain while some elderly clients may also avoid complaining about pain. Option A is incorrect; the nurse should assess for pain first. Options B and C may be done if the nurse can’t identify the cause of altered behavior.
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