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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","E"]

Explanation

Choice A rationale
Packs of cigarettes smoked per day is essential information for calculating smoking pack years.
Choice B rationale
The number of attempts to quit smoking is not required for calculating smoking pack years.
Choice C rationale
The client’s current age is not required for calculating smoking pack years.
Choice D rationale
While this helps you calculate the total years if the client hasn't done the math themselves, the ageitself is not a variable in the final formula.
Choice E rationale
The number of years the client smoked is essential for calculating smoking pack years.

A. Observe for jugular vein distention while the client is flat in bed. B. Auscultate breath sounds while the client is supine. C. Measure the blood pressure when the client is lying and standing. D. Ask the client how many pillows are used to sleep on at night.

Correct Answer is D

Explanation

Choice D rationale
Orthopnea is a condition where individuals have difficulty breathing while lying flat and may need to sleep with multiple pillows or in a more upright position to alleviate symptoms.
Therefore, asking the client about the number of pillows used for sleep can provide valuable information about the presence and severity of orthopnea.
Choice A rationale
While jugular vein distention can indicate fluid overload or heart failure, it is not a direct assessment of orthopnea, which is the difficulty breathing while lying flat.
Choice B rationale
Auscultating breath sounds while the client is supine can provide information about lung function and the presence of abnormal breath sounds, but it does not specifically address orthopnea.
Choice C rationale
Measuring the blood pressure when the client is lying and standing assesses for orthostatic hypotension, which is a drop in blood pressure upon standing. While orthostatic hypotension can contribute to symptoms of dizziness or fainting upon assuming an upright position, it does not directly assess orthopnea.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

While obtaining a client’s health history related to smoking cigarettes, the nurse plans to determine the client’s smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.

Correct Answer is ["A","E"]

Explanation

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?

Correct Answer is D

Explanation

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?

Heart sounds are loudest for S1 at the ______ and S2 at the _____.

Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client’s paresthesia?

The nurse observes that a client is experiencing melena.Which serum laboratory test should the nurse monitor in response to this finding?

The nurse asks a female client about the proverb “Glass Houses,” and she replies, “It will break the windows.”. Which conclusion should be documented about this client’s response?

When performing a neurologic assessment on an alert client, the nurse observes that the client’s pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

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?