A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment?

Difficulty hearing low pitch

Increased taste discrimination

Impaired night vision

Heightened sense of smell

Answer and Explanation

The Correct Answer is C

Choice A reason: Difficulty hearing low pitch is not a typical age-related change. Presbycusis, common in older adults, primarily affects high-frequency hearing, making it hard to discern high-pitched sounds like consonants. Low-pitch hearing is generally preserved. This choice does not reflect a normal sensory change, as it misaligns with the expected auditory decline in aging.

Choice B reason: Increased taste discrimination is incorrect, as aging typically reduces taste sensitivity due to fewer taste buds and altered salivary function. Older adults often report diminished flavor perception, impacting appetite. This choice is not a normal sensory change, as it contradicts the expected decline in gustatory function associated with aging.

Choice C reason: Impaired night vision is a normal age-related change due to presbyopia and reduced pupil dilation, decreasing retinal light sensitivity. Older adults struggle with low-light conditions, increasing fall risk. This change, linked to lens yellowing and slower dark adaptation, is expected and aligns with typical visual decline in aging populations.

Choice D reason: Heightened sense of smell is not typical in older adults. Aging reduces olfactory sensitivity due to fewer olfactory neurons and mucosal changes, impairing smell detection. This can affect safety, like detecting gas leaks. This choice is incorrect, as it opposes the normal decline in olfactory function seen in aging.

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Correct Answer is A

Explanation

Choice A reason: The FACES scale, using facial expressions, is validated for children aged 4, allowing them to express pain nonverbally when verbal skills are limited. It’s reliable, age-appropriate, and ensures accurate pain assessment, guiding interventions like analgesics to alleviate discomfort, critical for pediatric care and improving child comfort and recovery.

Choice B reason: Checking previous charting provides historical context but doesn’t assess current pain in a 4-year-old, whose pain fluctuates. Direct assessment with tools like the FACES scale is needed for accuracy. Relying on records risks missing present pain, delaying interventions and potentially prolonging discomfort in a young child.

Choice C reason: A 0 to 10 pain scale is too abstract for a 4-year-old, who lacks the cognitive ability to quantify pain numerically. The FACES scale better suits their developmental stage. Using this scale risks inaccurate assessment, leading to under- or overtreatment, compromising pain management in pediatric patients.

Choice D reason: Asking parents about the child’s pain relies on subjective interpretation, not the child’s direct experience. The FACES scale allows the child to communicate pain themselves, ensuring accuracy. Parental input may supplement but not replace child-focused assessment, risking misjudgment of pain severity and delaying appropriate interventions.

A. It sounds like you have lost energy. B. It sounds like you have lost hope. C. It sounds like you have lost the ability to sleep. D. It sounds like you have lost your appetite.

Correct Answer is B

Explanation

Choice A reason: Acknowledging lost energy restates a symptom but does not address the patient’s emotional state. The patient’s statement, “What’s the use?” suggests despair beyond physical fatigue. This response misses the opportunity to explore psychological distress, limiting therapeutic communication and failing to support the patient’s emotional needs in a terminal illness.

Choice B reason: Stating “It sounds like you have lost hope” reflects the patient’s despair, as indicated by disinterest in work, care, and the phrase “What’s the use?” This empathetic response opens dialogue about emotional and spiritual needs, fostering trust. It aligns with holistic care, addressing the psychological impact of a terminal diagnosis effectively.

Choice C reason: Focusing on lost sleep restates a symptom without addressing the underlying hopelessness. Sleep issues are secondary to the patient’s emotional distress in a terminal illness. This response fails to engage with the patient’s despair, missing a chance to provide emotional support and explore deeper psychological or spiritual concerns.

Choice D reason: Noting lost appetite acknowledges a physical symptom but ignores the patient’s emotional withdrawal and hopelessness. The statement “What’s the use?” points to existential distress, not just eating issues. This response lacks depth, failing to address the psychological and spiritual dimensions critical in terminal illness care.

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A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 4-year-old child who is demonstrating signs of pain. Which technique will the nurse use to best assess pain in this child?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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