An older adult client reports noticing an increased difficulty hearing over the past year. The client explains that words often sound garbled and the end of sentences are often missed. Which follow up question is best for the nurse to ask?

"Have you ever considered being evaluated for a hearing aid?"

"Do you have a history of ear infections?"

"Is this hearing loss accompanied by any loss of balance?"

"How is this hearing loss interfering with your daily activities of living?"

Answer and Explanation

The Correct Answer is D

Rationale:
A. "Have you ever considered being evaluated for a hearing aid?": Suggesting a hearing aid too early may feel dismissive and presumes a diagnosis without a full assessment. First, the nurse needs to understand the impact and specifics of the hearing loss before recommending interventions like hearing aids.

B. "Do you have a history of ear infections?": A history of ear infections is relevant because recurrent infections can lead to conductive hearing loss. However, the pattern described—garbled words and missed sentence endings—suggests possible sensorineural hearing loss (presbycusis), making a broader functional assessment more appropriate first.

C. "Is this hearing loss accompanied by any loss of balance?": Hearing loss combined with balance issues could suggest vestibular involvement. However, in the absence of the client mentioning dizziness or falls, the more pressing need is to assess how hearing difficulties are impacting daily functioning and quality of life.

D. "How is this hearing loss interfering with your daily activities of living?": Understanding how the hearing loss affects activities of daily living helps the nurse assess the severity and functional impact. This client-centered approach guides both the urgency of intervention and the planning of supportive resources to enhance the client’s quality of life.

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Correct Answer is ["A","B","E","F","G"]

Explanation

Rationale:
A. Glasgow coma scale: The Glasgow Coma Scale (GCS) assesses eye-opening, verbal response, and motor response. This is essential in a client admitted to a stroke unit to monitor changes in neurological function and detect early signs of deterioration.

B. Pupil size: Assessing pupil size and reactivity is critical because changes can indicate increased intracranial pressure or focal neurological damage. In a post-fall, stroke-risk client, monitoring pupils helps detect worsening brain injury.

C. Brudzinski reflexes: Brudzinski's sign is used to assess meningeal irritation, commonly seen in meningitis, not stroke. There is no indication of meningeal infection in this client’s presentation, so this reflex is not relevant here.

D. Romberg's test: Romberg's test evaluates balance and proprioception, typically used for clients with suspected vestibular or sensory ataxia. Given the client's acute condition and history of carotid disease, balance testing could be unsafe immediately after a fall.

E. Muscle tone: Assessment of muscle tone is important because stroke and carotid artery disease can lead to changes such as spasticity or flaccidity. Early detection of abnormal muscle tone supports quick rehabilitation planning and fall prevention strategies.

F. Level of consciousness: Monitoring level of consciousness (LOC) is crucial in stroke clients. Changes in LOC can be early indicators of worsening cerebral perfusion, hemorrhage, or new ischemic events, all of which require immediate intervention.

G. Cranial nerves: Cranial nerve assessment is essential in stroke evaluation because deficits can reveal specific areas of brain involvement. Testing functions like facial movement, swallowing, and visual fields helps complete a thorough neurological picture.

A. Fingernail pitting present. B. Nail care needed. C. Capillary refill less than 3 seconds. D. Nailbeds pink.

Correct Answer is D

Explanation

Rationale:
A. Fingernail pitting present: Fingernail pitting appears as small depressions or pits on the nail surface, often seen in psoriasis. The client's nails in the photo are smooth and intact, showing no signs of pitting, so this option is not accurate.

B. Nail care needed: Nail care would be documented if there were overgrown, broken, dirty, or neglected nails. The nails shown are clean and neatly maintained, meaning nail care is not an immediate need for this client.

C. Capillary refill less than 3 seconds: Capillary refill time measures circulation but is not assessed just by observing nail color. It requires pressing the nail and timing how quickly color returns, which is not part of this static assessment.

D. Nailbeds pink: Pink nailbeds indicate good peripheral circulation and oxygenation. In the photo, the client's nailbeds are visibly pink without cyanosis, discoloration, or pallor, making this the correct documentation of the findings.

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An older adult client reports noticing an increased difficulty hearing over the past year. The client explains that words often sound garbled and the end of sentences are often missed. Which follow up question is best for the nurse to ask?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.

Correct Answer is ["A","B","E","F","G"]

Explanation

The nurse assesses a client's fingernails as seen in the photo. How should the nurse document the findings?

Correct Answer is D

Explanation

To assess for the presence of kyphosis, which action should the nurse take?

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