The nurse is evaluating a client's hearing who reports hearing best in the left ear although words are muffled during conversation at a social gathering. Based on this finding, which assessment should the nurse implement?

Inspect the external ear canals.

Ask client if he has tinnitus.

Determine ability to maintain balance with eyes closed.

Differentiate ability to hear high and low pitched sounds.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Inspect the external ear canals: Muffled hearing, especially if unilateral, may be due to cerumen impaction, swelling, or other obstructions in the external auditory canal. Visual inspection is a quick, non-invasive first step that can help identify mechanical causes of hearing difficulty before pursuing more complex diagnostic tests.

B. Ask client if he has tinnitus: Tinnitus refers to ringing or buzzing in the ears and is often associated with sensorineural hearing loss rather than conductive hearing loss, which is more likely when hearing is muffled. While relevant for a full hearing evaluation, it does not address the immediate symptom of muffled hearing.

C. Determine ability to maintain balance with eyes closed: Balance issues are more related to inner ear dysfunction, particularly involving the vestibular system. Since the client's primary complaint is muffled hearing and not dizziness or balance problems, this assessment is not the most appropriate first step.

D. Differentiate ability to hear high and low pitched sounds: Differentiating pitch perception helps assess for specific types of sensorineural hearing loss. However, before conducting specialized auditory discrimination tests, it is more appropriate to first check for any external, easily correctable issues such as blockage or infection.

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Correct Answer is D

Explanation

Rationale:
A. Excess vellus hair: Vellus hair is fine, short, unpigmented hair that covers most of the body. It is not related to hair dye use and would not be a typical finding when assessing the scalp hair of someone who frequently dyes their hair.

B. Receding front hairline: A receding hairline is usually related to hormonal changes, aging, or genetic predisposition rather than the direct effects of frequent hair dyeing. Hair dye may damage hair texture, but it does not typically cause patterned hair loss at the hairline.

C. Fine, thin, limp texture: Fine and limp hair is often linked to factors like genetics, aging, or nutritional deficiencies. While hair dye can weaken hair, the more expected result from repeated chemical exposure is a coarse, dry, and brittle texture rather than a limp appearance.

D. Coarse, dry, brittle texture: Frequent chemical dyeing damages the hair cuticle, leading to dryness, roughness, and increased fragility. Palpating the client's scalp would likely reveal hair that feels coarse and brittle, consistent with the effects of long-term chemical processing.

A. Hematocrit. B. Serum calcium. C. Hemoglobin. D. Serum prealbumin.

Correct Answer is D

Explanation

Rationale:
A. Hematocrit: Hematocrit measures the proportion of red blood cells in the blood and helps assess for anemia or dehydration, but it does not directly reflect short-term changes in nutritional status or protein stores.

B. Serum calcium: Serum calcium levels assess electrolyte balance and bone health but are not specific indicators of overall nutritional status. Calcium levels can be maintained even when nutritional intake is poor.

C. Hemoglobin: Hemoglobin evaluates oxygen-carrying capacity and can suggest anemia, which may indirectly reflect poor nutrition, but it is not as sensitive a marker for acute or current nutritional status as prealbumin.

D. Serum prealbumin: Serum prealbumin is a sensitive marker of recent nutritional intake and protein status, reflecting short-term changes in nutrition. It is the most important laboratory value to assess when evaluating a client for malnutrition, especially in the setting of appetite loss and generalized malaise.

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The nurse is evaluating a client's hearing who reports hearing best in the left ear although words are muffled during conversation at a social gathering. Based on this finding, which assessment should the nurse implement?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

An older adult client is admitted to the medical unit because of a loss of appetite and generalized malaise. To analyze the client's general nutritional status, which laboratory value is most important for the nurse to review?

Correct Answer is D

Explanation

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