The nurse is assessing a client admitted on the medical surgical unit. The patient has no complaints of pain or distress noted. The temp is 98.6°F, pulse of 88, respirations of 18 and blood pressure of 172/88. The patient's electronic health record notes a diagnosis of esotropia that has been present for the past five years. The nurse is providing an external eye exam. What priority finding would the nurse expect from the client?

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.

Choice A reason: Morphine treats severe pain but isn’t first-line for headaches worsened by coughing, which may signal increased intracranial pressure. Without neurological assessment, this risks masking symptoms of serious conditions like brain tumors, delaying critical diagnosis and intervention.

Choice B reason: Palpating occipital lymph nodes checks for infection or inflammation, but headaches worsened by coughing or sneezing suggest intracranial issues, not lymphatic ones. This action misses the priority of assessing brain function tied to the client’s specific symptom pattern.

Choice C reason: Neurological assessment, like checking reflexes or pupil response, is vital for morning headaches worsening with coughing, hinting at possible intracranial pressure from masses or bleeds. It’s the most direct step to rule out life-threatening causes promptly.

Choice D reason: Explaining migraines assumes a diagnosis without evidence. Morning headaches improving later, worsened by strain, don’t align with typical migraine patterns, risking misdiagnosis of serious conditions like sinus thrombosis, necessitating neurological evaluation over premature reassurance.