A nurse is caring for a client who has presbycusis. Which of the following actions should the nurse take?
Sit by the client's side and speak very slowly.
Speak directly to the client, a little more slowly, in a normal, clear voice.
Prepare to remove the blockage in the ear.
Raise your voice and speak loudly and into the client's good ear.
The Correct Answer is B
Choice A reason: Speaking very slowly distorts speech, worsening comprehension in presbycusis, an age-related high-frequency hearing loss. Facing the client aids lip-reading, but excessive slowness disrupts natural cadence, reducing clarity for those with sensorineural deficits typically seen here.
Choice B reason: Speaking directly, slightly slower, in a clear voice enhances understanding in presbycusis. Facing the client supports visual cues, while normal volume avoids distortion, addressing high-frequency loss effectively without assuming blockage or overcompensating unnecessarily for this condition.
Choice C reason: Presbycusis is sensorineural, not conductive from blockages like cerumen. Preparing to remove nonexistent wax misdiagnoses this age-related cochlear degeneration, wasting time and missing the communication adjustments needed for effective care in this scenario entirely.
Choice D reason: Raising the voice distorts sound, worsening presbycusis comprehension, as shouting amplifies lower frequencies, not the lost high ones. Assuming a “good ear” ignores bilateral degeneration, making this less effective than clear, direct speech for communication here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Convergent response isn’t a standard term; convergence occurs with near focus, not light. This misnames the pupil constriction in the opposite eye from light stimulus, unrelated to the observed cranial nerve III reflex entirely here.
Choice B reason: Direct reflex is pupil constriction in the lit eye, not the other. This describes the same-side reaction, not the contralateral constriction observed, distinguishing it from the finding in this eye exam fully and accurately here.
Choice C reason: Consensual response is when light in one eye constricts the other’s pupil, via cranial nerve III. This matches the finding, reflecting normal optic and oculomotor nerve interplay, making it the precise description comprehensively here.
Choice D reason: Accommodation adjusts focus for near vision, constricting pupils bilaterally, not from unilateral light. This involves lens change, not the light-induced contralateral reflex seen, excluding it as the correct term in this scenario fully here.
Correct Answer is B
Explanation
Choice A reason: Cranial nerve VIII (vestibulocochlear) governs hearing and balance, not tongue strength. A deficit here causes vertigo or deafness, not motor weakness in the tongue, making it unrelated to the observed decrease in muscle power during examination.
Choice B reason: Cranial nerve XII (hypoglossal) controls tongue movement and strength. Weakness here, as noted, suggests nerve damage, like in stroke or ALS, impairing the tongue’s ability to push against resistance, directly explaining the finding accurately.
Choice C reason: Cranial nerve VI (abducens) moves the eye laterally, not the tongue. A problem here causes diplopia, not tongue weakness, disconnecting it from the motor function loss observed in the client’s oral examination entirely here.
Choice D reason: Cranial nerve III (oculomotor) controls eye movement and pupil response, not tongue strength. Its dysfunction leads to ptosis or eye deviation, irrelevant to the tongue’s motor impairment noted in this neurological assessment fully.
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