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.

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

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

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

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is B

Explanation

Choice A Reason:
Reviewing the client's serum electrolytes is incorrect. While abnormalities in electrolyte levels can sometimes contribute to neurological symptoms, such as paresthesia, reviewing the client's serum electrolytes may not directly identify additional findings consistent with the client's reported paresthesia of the hands and legs. Therefore, this option is less relevant for assessing paresthesia and identifying additional consistent findings.
Choice B Reason:
This is the correct action to identify additional findings consistent with the client's paresthesia. Paresthesia, or abnormal sensations like burning or tingling, may indicate neurological dysfunction. Assessing the client's muscle strength and hand grips can provide valuable information about neurological function and help identify any weakness or changes that may be associated with the paresthesia.
Choice C Reason:
Checking distal phalanges capillary refill is incorrect. Checking distal phalanges capillary refill is important for assessing peripheral circulation, but it may not directly identify additional findings consistent with paresthesia. While impaired circulation could contribute to sensory disturbances, such as paresthesia, it is not always the primary cause. Therefore, this option may not fully capture the sensory aspect of the client's reported symptoms.
Choice D Reason:
While observing the skin for signs of inflammation or irritation is important in assessing for other conditions, such as infection or inflammation, it is not directly related to identifying additional findings consistent with paresthesia. Paresthesia primarily involves abnormal sensations and neurological function rather than changes in the skin.

A. Test feet for a positive Babinski reflex. B. Observe color of the feet and toes. C. Measure skin elasticity around the ankles. D. Assess volume of the pedal pulses. E. Palpate dorsal surface of feet for warmth.

Correct Answer is ["B","D","E"]

Explanation

Choice A Reason:
Testing feet for a positive Babinski reflex is wrong. The Babinski reflex is a neurological test that assesses upper motor neuron function, particularly in the lower extremities. However, it is not relevant to assessing cold feet, and testing for the Babinski reflex would not provide useful information in this situation.
Choice B Reason:
Observing color of the feet and toes is wright. Observing the color of the feet and toes can provide important information about circulation. Pallor, cyanosis, or mottling may indicate inadequate blood flow or perfusion to the extremities, which could contribute to cold feet.
Choice C Reason:
Measuring skin elasticity around the ankles is wrong. Skin elasticity assessment is more relevant for evaluating hydration status or tissue turgor. While it may be useful in certain contexts, it is not directly related to assessing cold feet and peripheral circulation. Therefore, it is not necessary before covering the client's feet in this scenario.
Choice D Reason:
Assessing volume of the pedal pulses is wright. Assessing the volume of the pedal pulses (such as dorsalis pedis and posterior tibial pulses) provides information about peripheral vascular status. Weak or absent pulses may indicate compromised circulation, contributing to cold feet.
Choice E Reason:
Palpating dorsal surface of feet for warmth is wright. palpating the dorsal surface of the feet for warmth helps assess peripheral perfusion. Coolness to touch may indicate decreased blood flow to the extremities, while warmth suggests adequate circulation.

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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

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?

Correct Answer is B

Explanation

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Correct Answer is ["B","D","E"]

Explanation

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