An older adult client comes to the healthcare provider's office for a routine follow up exam for high blood pressure, osteoarthritis, constipation, and chronic sinusitis. The client recently had a cataract removed from the left eye. Which is most important for the nurse to address when obtaining this client's health history?

Conduct an assessment of functional capacity and environmental hazards.

Obtain a medication history including prescription and non prescription drugs.

Distinguish between symptoms caused by disease and those due to aging.

Emphasize the need to place advance directives in the medical record.

Answer and Explanation

The Correct Answer is A

A.   Assessing the client's functional capacity and identifying potential environmental hazards is essential, especially in older adults, as they may face physical limitations or risks in their environment that could impact their safety and quality of life.
B.   Medication history is always important, particularly in older adults who may be taking multiple medications for chronic conditions. However, while relevant, it is not the most critical aspect in this scenario.
C.   Differentiating between symptoms of aging and those caused by disease is important for accurate diagnosis and treatment. However, the priority should be to assess the client's overall health and risks related to their daily function and environment.
D.   While discussing advance directives is essential for future care planning, it is not the immediate priority in this health history assessment. The focus should be on addressing any current health issues that impact the client’s quality of life.

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Correct Answer is D

Explanation

A. Otitis media is an infection of the middle ear, and while it can affect hearing, it is not typically assessed using a tuning fork. Tuning forks are more useful for evaluating conductive hearing loss or bone conduction.
B. A tuning fork is generally not used to assess neurological pathology directly. Neurological conditions often require other diagnostic tools or tests to evaluate nerve function or reflexes.
C. Tinnitus is the perception of ringing in the ears and is usually assessed through patient reporting and audiometric testing. A tuning fork is not used to diagnose tinnitus, but it may be used to test hearing acuity.
D. A tuning fork is commonly used to assess for hearing loss, specifically conductive hearing loss. The fork helps test the function of bone and air conduction, which are important for determining the type of hearing impairment.

Correct Answer is []

Explanation

Condition: Pleural Effusion

Pleural effusion is an accumulation of fluid in the pleural space, leading to difficulty breathing, decreased lung sounds, and dullness upon percussion (as noted in the nurse's assessment).

Actions to Take:

Auscultate the lungs for adventitious breath sounds: Pleural effusion may result in decreased or absent breath sounds due to fluid in the pleural cavity. Adventitious sounds such as crackles or a pleural friction rub can sometimes be heard, but in this case, decreased sounds are noted.
Inspect the chest for lag on the affected side: In pleural effusion, there may be a delay in chest expansion on the affected side due to fluid buildup, which is consistent with the decreased expansion noted in the assessment.

Parameters to Monitor:

Cyanosis: Cyanosis may occur if the fluid accumulation severely impairs oxygenation.
Respiratory rate and pulse: Monitoring respiratory rate and pulse is critical to assess for signs of respiratory distress and hypoxia, which could result from the pleural effusion.

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Naxlex Comprehensive Predictor Exams

When conducting a physical examination, the nurse uses a tuning fork to assess for which condition?

Correct Answer is D

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

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