A nurse in an outpatient clinic is caring for a client. Which of the following findings indicates the client is experiencing a hearing deficit?

Persistent repositioning of objects

No response to tactile stimuli

Decreased attention span

Presence of expressive aphasia

Answer and Explanation

The Correct Answer is C

A. Persistent repositioning of objects: Repositioning objects frequently is more likely to be related to issues like anxiety or cognitive concerns rather than a hearing deficit. It does not typically indicate a hearing issue.

B. No response to tactile stimuli: No response to tactile stimuli suggests a possible sensory deficit related to touch or neurological concerns, but it does not indicate a hearing deficit. Hearing deficits affect auditory perception, not tactile sensations.

C. Decreased attention span: A decreased attention span can be a sign of hearing impairment, as individuals with hearing deficits may have difficulty following conversations or may become distracted due to not fully engaging with their environment.

D. Presence of expressive aphasia: Expressive aphasia is related to difficulty with speech production and language, typically following neurological events like strokes. It is not directly associated with hearing deficits but rather with language processing.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Apply a moisture barrier ointment to the area in contact with urine: Applying a moisture barrier ointment is an essential intervention to protect the skin from moisture-related irritation and breakdown. This helps prevent skin damage from prolonged exposure to urine.

B. Assist with toileting every 4 hr while awake: While regular toileting is important for managing urinary incontinence, the client should be encouraged to use the bathroom based on individual needs. Toileting every 4 hours may not meet the client’s needs for more frequent voiding.

C. Instruct the client to consume fluids between 0600 and 2200: Limiting fluid intake to specific hours is not recommended unless there is a medical need. Adequate hydration is essential, and restricting fluid intake could lead to dehydration or urinary tract infections.

D. Cleanse the skin with antibacterial soap and hot water after each incontinence episode: Antibacterial soap and hot water can be too harsh on the skin, potentially leading to dryness and irritation. It’s better to use mild soap and warm water to cleanse the skin gently.

A. Warm skin B. Restlessness C. Bounding pulses D. Brisk capillary refill

Correct Answer is B

Explanation

A. Warm skin: Warm skin typically indicates good circulation and is not a specific sign of active bleeding. Active bleeding is more likely to cause signs like cool or pale skin due to decreased perfusion.

B. Restlessness: Restlessness is a common sign of hypovolemia or decreased oxygen perfusion, both of which can be caused by active bleeding. It may indicate that the client is experiencing discomfort, anxiety, or shock due to blood loss.

C. Bounding pulses: Bounding pulses are typically associated with conditions like fever or increased blood volume, not bleeding. Active bleeding usually results in weak, thready pulses due to decreased blood volume.

D. Brisk capillary refill: A brisk capillary refill time (less than 2 seconds) is generally a sign of adequate circulation, not bleeding. In the case of active bleeding, capillary refill may be delayed due to reduced blood flow.

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A nurse in an outpatient clinic is caring for a client. Which of the following findings indicates the client is experiencing a hearing deficit?

Nursing Test Bank

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