During an admission assessment, which approach should the nurse use to assess a client's speech patterns?

Note the client's responses during the initial interview.

Ask the client to complete a common proverb or saying.

Listen while the client reads items listed on the menu.

Have the client repeat a phrase containing alliteration.

Answer and Explanation

The Correct Answer is A

A. Note the client's responses during the initial interview. This allows the nurse to observe the client's natural speech patterns in a conversational context, which is a realistic and comprehensive way to assess speech.

B. Ask the client to complete a common proverb or saying. This approach assesses the client's understanding and familiarity with language but may not comprehensively evaluate speech patterns.

C. Listen while the client reads items listed on the menu. This tests reading ability and articulation but may not reflect the client’s natural speech patterns during conversation.

D. Have the client repeat a phrase containing alliteration. This can help assess speech articulation and clarity but is not comprehensive for evaluating overall speech patterns.

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Correct Answer is A

Explanation

A. Observation of cervical range of motion reveals flexion and extension is 25 degrees. This limited range of motion indicates a significant restriction, which could be related to lifestyle factors such as posture, ergonomics at work, or physical activities.

B. Evaluation of cranial nerve XI reveals flexion is maintained against full resistance. This finding is normal and suggests good strength and function of the sternocleidomastoid and trapezius muscles, not necessarily related to lifestyle habits.

C. Inspection of head and neck is observed in a straight alignment without lateral curves. This is a normal finding and does not indicate any need for further inquiry about lifestyle habits.

D. Palpation of the spinous processes and surrounding muscles are non-tender. This is a normal finding, indicating no immediate issues with the cervical spine or surrounding muscles that would necessitate further lifestyle inquiries.

A. Begin to orient the client to her surroundings in the hospital room. B. Stand directly in front of the client and ask about any hearing loss. C. Obtain a tuning fork to complete Rinne and Weber tuning fork tests. D. Perform a mental status exam to assess the client's thought processes.

Correct Answer is B

Explanation

A. Begin to orient the client to her surroundings in the hospital room. Orienting the client is important but does not address the immediate issue of possible hearing loss, which might be causing the client's behavior.

B. Stand directly in front of the client and ask about any hearing loss. This is the best choice because it addresses the possible reason for the client's behavior directly. Standing in front of the client helps ensure she can see and hear the nurse clearly.

C. Obtain a tuning fork to complete Rinne and Weber tuning fork tests. These tests are useful for diagnosing hearing loss but are not the first step. Initial assessment should involve direct communication to identify the issue.

D. Perform a mental status exam to assess the client's thought processes. While assessing mental status is important, it does not address the immediate observation that the client may have hearing loss.

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During an admission assessment, which approach should the nurse use to assess a client's speech patterns?

Nursing Test Bank

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