A nurse in an outpatient clinic is caring for a client. Which of the following findings indicates the client is experiencing a hearing deficit?
No response to tactile stimuli
Presence of expressive aphasia
Decreased attention span
Persistent repositioning of objects
The Correct Answer is C
Rationale
A. No response to tactile stimuli: Lack of response to tactile stimuli indicates a problem with the sense of touch, not hearing. Assessing tactile response helps evaluate somatosensory function rather than auditory function.
B. Presence of expressive aphasia: Expressive aphasia is a language disorder usually caused by neurological injury, such as a stroke, and is not directly related to hearing loss. It affects speech production rather than auditory perception.
C. Decreased attention span: A client with a hearing deficit may have difficulty following conversations or instructions, which can manifest as decreased attention or apparent inattentiveness. Difficulty processing auditory information is a common indicator of hearing impairment.
D. Persistent repositioning of objects: Frequently moving or rearranging objects is more indicative of cognitive or organizational issues rather than a hearing deficit. This behavior does not typically reflect impaired auditory function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Circular Red Area: This is a Stage 1 Pressure Injury (non-blanchable erythema or shallow ulcer).
B. Bruise on Leg: This shows contusion/bruising (ecchymosis) and possible swelling, which is a closed injury, not an open wound that requires healing by intention.
C. Sutured Incision (Primary intention): The wound edges are cleanly approximated (brought together) with sutures, staples, or adhesive. Minimal tissue loss occurred. Healing occurs rapidly, with minimal granulation tissue and minimal scarring. The image showing the clean, surgical incision closed with staples or sutures.
D. Open Ulcer/Pressure Injury (Secondary Intention): The wound has significant tissue loss, irregular borders, and the edges cannot be approximated (closed). The wound is left open to heal by granulation (formation of new connective tissue) from the bottom up. This process is slower and results in a larger, more noticeable scar.
Correct Answer is D
Explanation
Rationale
A. Dry mucous membranes: Dry mucous membranes are typically a manifestation of dehydration or hyperglycemia, not hypoglycemia. They indicate fluid deficit rather than low blood glucose levels.
B. Thirst: Excessive thirst is associated with hyperglycemia and fluid loss due to osmotic diuresis. It is not a common symptom of hypoglycemia and does not indicate low blood glucose.
C. Polyuria: Polyuria occurs with hyperglycemia when the kidneys excrete excess glucose in the urine. It is not a feature of hypoglycemia and does not help identify low blood sugar episodes.
D. Shakiness: Shakiness or tremors is a classic manifestation of hypoglycemia. It results from adrenergic stimulation as the body responds to low blood glucose levels, prompting sympathetic nervous system activation and symptoms such as sweating, palpitations, and anxiety.
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