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

A) Diabetes mellitus: While diabetes can lead to various complications affecting the nails, such as yellowing or thickening due to poor circulation and infections, it is not typically associated with brittle, concave (spoon-shaped) nails.

B) Recent candida infection: Candida infections can affect the nails, causing them to become discolored, thickened, or separated from the nail bed, but they do not typically cause the nails to become brittle and concave.

C) Iron deficiency anemia: This condition is often associated with brittle, spoon-shaped (concave) nails, known as koilonychia. Iron deficiency anemia affects the oxygen-carrying capacity of the blood, which can lead to changes in the nail beds, making them appear concave and brittle.

D) Coronary heart disease: While coronary heart disease can lead to changes in the nails due to poor circulation, it is not commonly associated with the specific finding of brittle, concave nails. Other nail changes might include clubbing or cyanosis, but not typically koilonychia.

A. Papules. B. Excoriation. C. Wheals. D. Fissuring.

Correct Answer is C

Explanation

A) Papules: Papules are small, raised, solid bumps on the skin that are typically less than 1 centimeter in diameter. They can be a result of various skin conditions, but they are not specifically associated with allergic reactions to insect bites.

B) Excoriation: Excoriation refers to a scratch or abrasion on the surface of the skin, often resulting from scratching due to itching. While this can occur secondary to an allergic reaction, it is not a primary characteristic of such reactions.

C) Wheals: Wheals, also known as hives or urticaria, are raised, red or skin-colored welts on the skin that often itch and can appear rapidly in response to an allergen such as an insect bite. They are a characteristic feature of allergic reactions and are caused by the release of histamine.

D) Fissuring: Fissuring refers to deep cracks or splits in the skin. While it can occur in various skin conditions, it is not a typical manifestation of an allergic reaction to an insect bite.

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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

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