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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. A stage 2 pressure injury is more than just erythema; it involves partial-thickness skin loss.
B. A stage 2 pressure injury presents as a shallow open ulcer with a red or pink wound bed, indicating partial-thickness loss of dermis.
C. A deep pocket of infection and necrotic tissue describes a stage 3 or 4 pressure injury, not stage 2.
D. Visible subcutaneous tissue and sloughing are characteristics of stage 3 or 4 pressure injuries, not stage 2.

A. Ensure the client knows to stop baclofen before using other antispasmodics. B. Monitor intake and output every 8 hours. C. Advise the client to move slowly and cautiously when rising and walking. D. Evaluate muscle strength every 4 hours.

Correct Answer is C

Explanation

A. Baclofen should not be stopped abruptly as it can cause withdrawal symptoms. The client should consult their healthcare provider before using other antispasmodics.
B. Monitoring intake and output every 8 hours is not specific to baclofen administration.
C. Baclofen can cause dizziness, drowsiness, and hypotension. Advising the client to move slowly and cautiously when rising and walking helps prevent falls or injury due to these side effects.
D. While muscle strength assessment is important, it is not required every 4 hours and does not specifically address the common side effects of baclofen.

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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

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

Correct Answer is B

Explanation

The nurse is administering the muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?

Correct Answer is C

Explanation

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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?

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