A nurse is caring for a client who has presbycusis. Which of the following actions should the nurse take?

Sit by the client's side and speak very slowly.

Speak directly to the client, a little more slowly, in a normal, clear voice.

Prepare to remove the blockage in the ear.

Raise your voice and speak loudly and into the client's good ear.

Answer and Explanation

The Correct Answer is B

Choice A reason: Speaking very slowly distorts speech, worsening comprehension in presbycusis, an age-related high-frequency hearing loss. Facing the client aids lip-reading, but excessive slowness disrupts natural cadence, reducing clarity for those with sensorineural deficits typically seen here.

Choice B reason: Speaking directly, slightly slower, in a clear voice enhances understanding in presbycusis. Facing the client supports visual cues, while normal volume avoids distortion, addressing high-frequency loss effectively without assuming blockage or overcompensating unnecessarily for this condition.

Choice C reason: Presbycusis is sensorineural, not conductive from blockages like cerumen. Preparing to remove nonexistent wax misdiagnoses this age-related cochlear degeneration, wasting time and missing the communication adjustments needed for effective care in this scenario entirely.

Choice D reason: Raising the voice distorts sound, worsening presbycusis comprehension, as shouting amplifies lower frequencies, not the lost high ones. Assuming a “good ear” ignores bilateral degeneration, making this less effective than clear, direct speech for communication here.

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Correct Answer is B

Explanation

Choice A reason: Cranial nerve VIII (vestibulocochlear) governs hearing and balance, not tongue strength. A deficit here causes vertigo or deafness, not motor weakness in the tongue, making it unrelated to the observed decrease in muscle power during examination.
Choice B reason: Cranial nerve XII (hypoglossal) controls tongue movement and strength. Weakness here, as noted, suggests nerve damage, like in stroke or ALS, impairing the tongue’s ability to push against resistance, directly explaining the finding accurately.
Choice C reason: Cranial nerve VI (abducens) moves the eye laterally, not the tongue. A problem here causes diplopia, not tongue weakness, disconnecting it from the motor function loss observed in the client’s oral examination entirely here.
Choice D reason: Cranial nerve III (oculomotor) controls eye movement and pupil response, not tongue strength. Its dysfunction leads to ptosis or eye deviation, irrelevant to the tongue’s motor impairment noted in this neurological assessment fully.

A. The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. B. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. C. The nurse will ask the client to close his eyes, and will ask that he identify a familiar object placed in the client’s hand. D. The client is asked to identify the number of points felt when the nurse touches the client with the ends of two applicators at the same time.

Correct Answer is A

Explanation

Choice A reason: Graphesthesia tests cortical sensory function by tracing numbers on the palm with eyes closed. A right-sided stroke may impair this on the left side, making this the correct method to assess parietal lobe processing accurately here.
Choice B reason: Simultaneous bilateral touch tests extinction, not graphesthesia. This assesses neglect, not the ability to interpret shapes, missing the specific sensory integration focus needed for graphesthesia in this stroke assessment entirely and fully here.
Choice C reason: Identifying objects with eyes closed tests stereognosis, not graphesthesia. This evaluates tactile recognition, not number tracing, diverging from the precise cortical sensory skill targeted in this neurological exam for stroke effects here.
Choice D reason: Two-point discrimination tests sensory acuity, not graphesthesia. This measures point differentiation, not shape recognition, making it unrelated to assessing the parietal lobe’s interpretive ability post-stroke as intended in this scenario fully.

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A nurse is caring for a client who has presbycusis. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process in the lungs?

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The nurse has completed the assessment of the client's ears. A small/moderate amount of brown cerumen was found in both ears. Which action by the nurse is warranted?

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