An older adult client reports noticing increased difficulty hearing over the past year. The client explains that words often sound garbled and the end of sentences are often missed. Which follow-up question is best for the nurse to ask?

"How is this hearing loss interfering with your daily activities of living?"

"Is this hearing loss accompanied by any loss of balance?"

"Do you have a history of ear infections?"

"Have you ever considered being evaluated for a hearing aid?"

Answer and Explanation

The Correct Answer is B

A. Assessing the impact of hearing loss on daily activities is important but not the immediate follow-up question to understand the nature of the hearing loss.
B. Asking about balance issues is essential because it could indicate an inner ear problem, which often affects both hearing and balance.
C. A history of ear infections could be relevant but is not as immediately necessary for determining the cause of the current symptoms.
D. Considering a hearing aid is a step for management, but determining the nature and cause of the hearing loss is the priority.

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Correct Answer is A

Explanation

A. Dysphagia, or difficulty swallowing, significantly increases the risk of aspiration, especially when consuming a full liquid diet that may not be easily controlled in the mouth. Aspiration can lead to serious complications, such as aspiration pneumonia.
B. Oxygen administration via a face mask does not typically increase the risk of aspiration unless the client has underlying conditions affecting swallowing.
C. Sensory aphasia affects communication but does not directly impact the swallowing mechanism, so it poses less risk of aspiration compared to dysphagia.
D. While clients with a nasogastric tube may be at some risk for aspiration, the risk is lower compared to a client with dysphagia actively consuming liquids.

A. Clavicle. B. Sternum. C. Aortic site. D. Lung apex.

Correct Answer is D

Explanation

A. The clavicle is an important landmark but not the ideal starting point for auscultating breath sounds.
B. The sternum is also not the correct starting location for breath sound auscultation.
C. The aortic site is unrelated to lung auscultation.
D. The lung apex, located above the clavicle, is the correct location to begin auscultating anterior breath sounds. This systematic approach ensures all areas of the lungs are assessed for normal and abnormal breath sounds.

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An older adult client reports noticing increased difficulty hearing over the past year. The client explains that words often sound garbled and the end of sentences are often missed. Which follow-up question is best for the nurse to ask?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client is at greatest risk for aspiration?

Correct Answer is A

Explanation

When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

Correct Answer is D

Explanation

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