An older male client reports to the nurse that his feet are cold. Before covering the client's feet, which assessment(s) should the nurse complete? Select all that apply.

Choice A Reason:
Standing directly in front of the client and ask about any hearing loss is appropriate because the client's behavior of ignoring questions from the nurse and speaking loudly to her son suggests a potential hearing impairment. Standing directly in front of the client allows for better visibility of facial expressions and lip movements, which can aid in communication for individuals with hearing loss. Asking about any hearing loss helps the nurse gather important information to adapt communication strategies effectively.
Choice B Reason:
Obtaining a tuning fork to complete Rinne and Weber tuning fork tests involves conducting hearing tests using a tuning fork to assess for conductive or sensorineural hearing loss. While these tests are valuable for diagnosing hearing impairments, they are typically performed after obtaining a thorough history and initial assessment, including asking about any hearing loss. Therefore, this option is not the first action to take when communication difficulties are observed.
Choice C Reason:
Beginning to orient the client to her surroundings in the hospital room involves providing orientation to the client about her surroundings, which is important for promoting comfort and reducing anxiety, especially in a new environment like a hospital room. However, addressing potential hearing loss is the priority when the client's behavior suggests difficulty in communication. Once hearing impairment is ruled out or addressed, orientation to the surroundings can be initiated.
Choice D Reason:
Performing a mental status exam to assess the client's thought processes involves assessing the client's cognitive function and thought processes, which is important for understanding the client's overall mental status. While assessing mental status is an essential aspect of comprehensive nursing assessment, it may not directly address the observed communication difficulties related to potential hearing impairment. Therefore, addressing potential hearing loss should be the first action to ensure effective communication before proceeding with a mental status exam.

Choice A Reason:
Assessing conjunctival sacs of lower lids for pallor is incorrect. Pallor of the conjunctival sacs, or inner eyelids, may indicate anemia or decreased blood flow. While it can be a sign of various health conditions, it is not specific to jaundice. Jaundice is characterized by yellowing of the skin and sclerae (the white part of the eyes) due to elevated bilirubin levels in the blood, so assessing for pallor would not directly confirm jaundice.
Choice B Reason:
Observing the client's urine for dark orange color is incorrect. Dark orange urine may indicate concentrated urine or dehydration, but it is not specific to jaundice. Jaundice primarily manifests as yellowing of the skin and sclerae due to elevated bilirubin levels, rather than a change in urine color. While changes in urine color may occur in certain liver conditions, such as obstructive jaundice, it is not the most direct or reliable method to confirm jaundice.
Choice C Reason:
Examining client's sclera for icterus is correct. Icterus, or yellowing of the sclerae (the white part of the eyes), is a classic sign of jaundice. Elevated levels of bilirubin in the blood lead to the yellow discoloration of the sclerae, providing a direct visual confirmation of jaundice. Examining the sclerae for icterus is a quick and reliable method to confirm jaundice during a physical assessment.
Choice D Reason:
Reviewing recent serum bilirubin levels is incorrect. Reviewing recent serum bilirubin levels can provide objective data on bilirubin levels in the blood, which may support the diagnosis of jaundice. Elevated serum bilirubin levels are characteristic of jaundice. While this option provides valuable information, it may not be immediately available during a physical assessment and does not directly confirm jaundice visually, unlike examining the sclerae for icterus.