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?

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

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.

Answer and Explanation

The Correct Answer is C

A. Performing a mental status exam is important but may not be the immediate priority if the issue could be related to a more straightforward problem such as hearing loss.
B. Orienting the client to her surroundings is helpful but may not address the immediate concern of her ignoring questions, which could be due to hearing issues.
C. Standing directly in front of the client and asking about hearing loss addresses a possible issue with communication immediately. It is crucial to rule out hearing impairment before assuming other causes for the client's behavior.
D. Using a tuning fork to complete Rinne and Weber tests is a valid assessment for hearing loss but is a more specific test that may be implemented after the nurse initially assesses whether hearing loss is a potential issue.

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Correct Answer is B

Explanation

A. While a drug urine screen may be part of preoperative testing, it is not appropriate as the primary method for gathering a client's substance use history. Trust and accuracy in self-reporting should be encouraged.
B. Asking specifically about alcohol, marijuana, cocaine, heroin, and amounts helps the nurse gather detailed information on the client's substance use, which is critical for safe anesthesia and surgical planning. Using specific terms rather than general or stigmatizing language promotes open communication.
C. The terms "illegal" or "illicit" might carry stigma, potentially leading the client to withhold information. Using neutral, non-judgmental language is more effective.
D. While clients can decline to answer, the nurse should explain the importance of accurate health information for their safety and care. Encouraging open dialogue is better than allowing clients to skip important questions without understanding the implications.

A. Use a warmed bell of the stethoscope and place it lightly over the four quads B. Place the stethoscope in the ears with the earpieces pointing towards the ears C. Tum the suction off while auscultating D. Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent E. Palpate the abdomen before auscultating

Correct Answer is ["A","C","D"]

Explanation

A. Use a warmed bell of the stethoscope and place it lightly over the four quadrants
Using a warmed stethoscope helps to avoid discomfort for the patient and ensures better transmission of sound. The bell of the stethoscope is effective for detecting low-pitched sounds such as bowel sounds. Lightly placing the stethoscope over the four quadrants of the abdomen allows for thorough assessment of bowel sounds in each area.
B. Place the stethoscope in the ears with the earpieces pointing towards the ears
While this is a standard practice for proper use of a stethoscope to ensure correct sound conduction, it is not specific to assessing bowel sounds. This action is important for accurate auscultation but does not directly relate to the technique of assessing bowel sounds.
C. Turn the suction off while auscultating
Turning off the nasogastric tube suction is crucial because suction noise can interfere with the assessment of bowel sounds. Clear and accurate auscultation of bowel sounds requires a quiet environment to avoid misinterpretation of sounds. Therefore, it is important to turn off any equipment that might create noise during the assessment.
D. Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent
Auscultating for a minimum of 5 minutes is essential to confirm the absence of bowel sounds. This extended duration helps in making an accurate assessment, as bowel sounds can be intermittent, and it ensures that transient sounds are not missed. This step is critical before concluding that bowel sounds are absent.
E. Palpate the abdomen before auscultating
Palpating the abdomen before auscultating can alter bowel sounds due to the manipulation of the intestines, potentially leading to inaccurate assessment. It is recommended to auscultate first to avoid affecting the natural bowel sounds before physical examination. Palpation should be done after auscultation to assess for any physical abnormalities or tenderness.

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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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Correct Answer is B

Explanation

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Correct Answer is ["A","C","D"]

Explanation

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