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?

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

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

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

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

Answer and Explanation

The Correct Answer is B

Choice A rationale
Orienting the client to her surroundings is important but does not address the immediate issue of potential hearing impairment, which may be causing communication difficulties.
Choice B rationale
Standing directly in front of the client and asking about any hearing loss is the first action to take. The client’s behavior of ignoring questions and speaking loudly to her son suggests a potential hearing impairment. Addressing this issue first can help improve communication and ensure the client understands the nurse’s questions.
Choice C rationale
Obtaining a tuning fork to complete Rinne and Weber tuning fork tests is appropriate for assessing hearing acuity but should be done after initially addressing the potential hearing loss through direct questioning.
Choice D rationale
Performing a mental status exam to assess the client’s thought processes is important but should be done after addressing the potential hearing impairment, which may be the primary cause of the observed behavior.

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Correct Answer is B

Explanation

Choice A rationale
Placing the stethoscope over the clavicle is not the correct starting point for systematically auscultating anterior breath sounds.
Choice B rationale
The nurse should begin by placing the stethoscope over the lung apex, which is located just above the clavicle. This ensures a systematic approach to auscultation.
Choice C rationale
The aortic site is not relevant for auscultating breath sounds; it is used for cardiac auscultation.
Choice D rationale
Placing the stethoscope over the sternum is not the correct starting point for auscultating breath sounds.

A. Assure the client that her breasts are normal, and advise annual evaluations. B. Request a return visit after her menstrual period for a breast exam re-check. C. Explain to the client that an ultrasound of the breast will likely be necessary. D. Suggest that the client schedule a mammogram after her next menstrual period.

Correct Answer is A

Explanation

Choice A rationale
Generalized lumpiness of both breasts with no discrete masses and no nipple discharge is a common finding, especially before menstrual periods. Assuring the client that her breasts are normal and advising annual evaluations is appropriate.
Choice B rationale
Requesting a return visit after her menstrual period for a breast exam re-check is unnecessary if the findings are consistent with normal premenstrual changes.
Choice C rationale
Explaining to the client that an ultrasound of the breast will likely be necessary is not warranted based on the current findings.
Choice D rationale
Suggesting that the client schedule a mammogram after her next menstrual period is not necessary for a young adolescent with normal premenstrual breast changes.

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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

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

Correct Answer is B

Explanation

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 A

Explanation

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While performing a physical assessment, the nurse is unable to palpate the client’s pedal pulses. Which action should the nurse take?

When evaluating a client’s rectal bleeding, which findings should the nurse document?

While observing a client’s face, which assessment finding requires immediate intervention by the nurse?

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?