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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Free Nursing Study Resources

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

Explanation

Choice A Reason

Number of attempts to quit smoking is incorrect. While the number of attempts to quit smoking may provide insight into the client's smoking cessation efforts and motivation, it is not directly relevant to calculating smoking pack years. Pack years specifically quantify the amount and duration of smoking, rather than cessation attempts.

Choice B Reason:

Packs of cigarettes smoked per day is correct. The number of packs of cigarettes smoked per day is a crucial factor in calculating smoking pack years. Pack years are calculated by multiplying the number of packs smoked per day by the number of years the individual has smoked. This information provides a quantitative measure of smoking exposure over time.

Choice C Reason:

Client's current age is incorrect. While the client's current age may be relevant in assessing overall health, risks associated with smoking and in discussing smoking cessation strategies, it is not directly used in the calculation of smoking pack years. Pack years are based on the total duration of smoking and the average daily consumption of cigarettes, not the client's current age.

Choice D Reason:

Number of years the client smoked is correct. The number of years the client has smoked is a critical piece of information for calculating smoking pack years. Pack years are calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the individual has smoked. This helps quantify the duration of smoking history.

Choice E Reason:

Age when the client started smoking is correct. Knowing the age at which the client started smoking is essential for determining the duration of smoking history, which is a key component in calculating pack years. It helps provide a comprehensive understanding of the client's smoking habits and exposure to tobacco smoke over time.

A. Audible thud without pain. B. Rigidity and firmness. C. Rebound tenderness. D. Sharp, severe pain.

Correct Answer is D

Explanation

Choice A Reason:
Audible thud without pain is incorrect. An audible thud without pain would not be an expected response when percussing the costovertebral angle (CVA) in a client with pyelonephritis. Pyelonephritis typically presents with tenderness upon percussion of the CVA due to inflammation or infection of the kidneys. The absence of pain in this scenario would not be consistent with the expected response.
Choice B Reason:
Rigidity and firmness are incorrect. Rigidity and firmness upon percussion of the costovertebral angle (CVA) may suggest muscle tension or guarding, rather than the tenderness typically associated with kidney inflammation or infection such as pyelonephritis. While guarding can occur in response to pain, it is not the expected response when assessing for kidney tenderness.
Choice C Reason:
Rebound tenderness is incorrect. Rebound tenderness refers to the exacerbation of pain upon release of pressure, typically observed in conditions such as peritonitis. While rebound tenderness may be present in some abdominal conditions, it is not the expected response when percussing the costovertebral angle (CVA) to assess for kidney tenderness in pyelonephritis. In pyelonephritis, tenderness upon initial percussion is more indicative of the condition.
Choice D Reason:
Sharp, severe pain is correct. Sharp, severe pain upon percussing the CVA suggests tenderness, which can be indicative of kidney inflammation or infection, such as pyelonephritis. This finding would support the diagnosis and help guide further assessment and treatment.

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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 obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. Which information should the nurse obtain for this calculation? Select all that apply.

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

Explanation

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Correct Answer is D

Explanation

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?

The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

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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.

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?