While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

Stand directly in front of the client and ask about any hearing loss

Perform a mental status exam to assess the client's thought processes.

Begin to orient the client to her surroundings in the hospital room

Obtain a tuning fork to complete Rinne and Weber tuning fork tests.

Answer and Explanation

The Correct Answer is A

A) Stand directly in front of the client and ask about any hearing loss:
The client's behavior of ignoring questions and speaking loudly to her son may suggest a hearing impairment. By standing directly in front of the client and asking about any hearing loss, the nurse can assess whether hearing impairment might be contributing to the communication difficulties. This action addresses a potential physiological cause of the observed behavior and allows the nurse to gather essential information to adapt communication strategies effectively.

B) Perform a mental status exam to assess the client's thought processes:
While assessing the client's mental status is important, the observed behavior may be more indicative of a communication issue related to hearing loss rather than a cognitive impairment. Therefore, assessing hearing status would be more appropriate as the initial action.

C) Begin to orient the client to her surroundings in the hospital room:
Orienting the client to her surroundings is important for promoting comfort and reducing confusion, but it may not directly address the observed communication difficulties. Assessing for hearing loss should be prioritized to determine if it contributes to the client's behavior.

D) Obtain a tuning fork to complete Rinne and Weber tuning fork tests:
Conducting Rinne and Weber tuning fork tests may be indicated to assess hearing acuity and differentiate between conductive and sensorineural hearing loss. However, obtaining a tuning fork and performing these tests should occur after gathering initial information about the client's hearing status through direct questioning. Therefore, assessing for hearing loss should be the first action taken by the nurse.

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Correct Answer is B

Explanation

A) Ask the client if he knows the year he married his wife:
While this question may assess long-term memory, it relies on specific episodic memory of a past event. Assessing recent memory loss typically involves evaluating the ability to recall recent events or information.

B) Determine if the client can recall what he ate for breakfast:
Assessing the client's ability to recall recent events, such as what he ate for breakfast, can provide valuable information about recent memory function. This assessment is relevant to the family's concerns about recent memory loss.

C) Instruct the client to follow a three-step task:
Assessing the client's ability to follow a three-step task evaluates executive function and working memory but may not directly assess recent memory loss, which is the family's concern.

D) Tell the client to repeat a series of unrelated numbers:
Assessing the client's ability to repeat a series of unrelated numbers tests short-term memory but does not specifically address recent memory loss or the family's concerns about it.

A. Continue with the remainder of the client's physical assessment. B. Report the client's abnormal lung sounds to the healthcare provider. C. Ask the client to cough and then auscultate at the site again. D. Measure the client's oxygen saturation with a pulse oximeter.

Correct Answer is A

Explanation

A) Continue with the remainder of the client's physical assessment:
Vesicular breath sounds are normal breath sounds heard over the peripheral lung fields. Hearing vesicular sounds in the bases of both lungs posteriorly indicates normal air movement in the lungs. Therefore, there is no immediate concern or need for further action related to this finding. The nurse should continue with the remainder of the client's physical assessment.

B) Report the client's abnormal lung sounds to the healthcare provider:
Vesicular breath sounds are considered normal lung sounds and do not warrant reporting as abnormal. Reporting this finding to the healthcare provider would not be appropriate and may lead to unnecessary concern or intervention.

C) Ask the client to cough and then auscultate at the site again:
Coughing would not be necessary in response to hearing vesicular breath sounds, as these are normal lung sounds. Repeating the auscultation may not provide additional information beyond confirming the presence of normal breath sounds.

D) Measure the client's oxygen saturation with a pulse oximeter:
Measuring oxygen saturation with a pulse oximeter is not indicated in response to hearing vesicular breath sounds. These breath sounds are normal and do not necessarily indicate a problem with oxygenation. Therefore, measuring oxygen saturation would not be the appropriate action in this situation.

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While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When family members express their concern about their father's recent memory loss, which assessment should the nurse suggest?

Correct Answer is B

Explanation

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Correct Answer is A

Explanation

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