While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

Stand directly in front of the client and ask about any hearing loss

Perform a mental status exam to assess the client's thought processes.

Begin to orient the client to her surroundings in the hospital room

Obtain a tuning fork to complete Rinne and Weber tuning fork tests.

Answer and Explanation

The Correct Answer is A

A) Stand directly in front of the client and ask about any hearing loss:
The client's behavior of ignoring questions and speaking loudly to her son may suggest a hearing impairment. By standing directly in front of the client and asking about any hearing loss, the nurse can assess whether hearing impairment might be contributing to the communication difficulties. This action addresses a potential physiological cause of the observed behavior and allows the nurse to gather essential information to adapt communication strategies effectively.

B) Perform a mental status exam to assess the client's thought processes:
While assessing the client's mental status is important, the observed behavior may be more indicative of a communication issue related to hearing loss rather than a cognitive impairment. Therefore, assessing hearing status would be more appropriate as the initial action.

C) Begin to orient the client to her surroundings in the hospital room:
Orienting the client to her surroundings is important for promoting comfort and reducing confusion, but it may not directly address the observed communication difficulties. Assessing for hearing loss should be prioritized to determine if it contributes to the client's behavior.

D) Obtain a tuning fork to complete Rinne and Weber tuning fork tests:
Conducting Rinne and Weber tuning fork tests may be indicated to assess hearing acuity and differentiate between conductive and sensorineural hearing loss. However, obtaining a tuning fork and performing these tests should occur after gathering initial information about the client's hearing status through direct questioning. Therefore, assessing for hearing loss should be the first action taken by the nurse.

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Correct Answer is C

Explanation

Answer: C. Assure the client that her breasts are normal, and advise annual evaluations.

Rationale:

A. Suggest that the client schedule a mammogram after her next menstrual period:
A mammogram is generally not indicated for adolescents unless there are specific concerns such as a family history of breast cancer or the presence of abnormal findings. Given the client's age and the findings of generalized lumpiness without discrete masses, a mammogram would not be the most appropriate action at this stage.

B. Explain to the client that an ultrasound of the breast will likely be necessary:
An ultrasound is typically used for further evaluation if discrete masses are found or if there are unusual characteristics in the breast tissue. In this case, the generalized lumpiness is likely related to normal physiological changes, making an ultrasound unnecessary at this time.

C. Assure the client that her breasts are normal, and advise annual evaluations:
The findings of generalized lumpiness and tenderness before menstruation are consistent with normal physiological changes associated with the menstrual cycle, often due to hormonal fluctuations. Providing reassurance and advising annual evaluations is appropriate, as it addresses the client's concerns and promotes confidence in her breast health without unnecessary interventions.

D. Request a return visit after her menstrual period for a breast exam re-check:
While a follow-up can be beneficial, it may not be necessary in this case since the findings are typical of normal breast tissue changes associated with the menstrual cycle. Reassuring the client and encouraging annual evaluations is a more effective approach than suggesting an unnecessary follow-up visit.

A. Sharp, severe pain. B. Audible thud without pain. C. Rigidity and firmness. D. Rebound tenderness.

Correct Answer is A

Explanation

A) Sharp, severe pain:
Percussion of the costovertebral angle (CVA) elicits sharp, severe pain in a client with pyelonephritis. This response indicates inflammation of the kidney and surrounding tissues, which is typical in pyelonephritis.

B) Audible thud without pain:
An audible thud without pain is a normal finding when percussing the CVA and would not be expected in a client with pyelonephritis.

C) Rigidity and firmness:
Rigidity and firmness may be related to muscle guarding or abdominal assessment findings, but they are not specific to CVA percussion and pyelonephritis.

D) Rebound tenderness:
Rebound tenderness is a sign of peritoneal irritation and is assessed by pressing on the abdomen and quickly releasing. It is not the typical finding associated with CVA percussion in pyelonephritis.

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While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

Correct Answer is C

Explanation

Rationale:

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Correct Answer is A

Explanation

When family members express their concern about their father's recent memory loss, which assessment should the nurse suggest?

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When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

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During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?