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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pulse volume is not the same as the presence of a bruit, which is an abnormal sound heard over an artery.
B. A bruit is an abnormal, blowing, or swishing sound heard over an artery, indicating turbulent blood flow, often due to atherosclerosis or narrowing of the artery. Documenting the presence of a bruit on the left and its absence on the right is the correct approach.
C. A strong pulse does not necessarily correlate with the presence of a bruit, and the absence of sound on the right does not confirm occlusion.
D. Occlusion of the artery cannot be confirmed solely based on the absence of a bruit; further diagnostic testing would be required.
Correct Answer is C
Explanation
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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