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

A. Begin to orient the client to her surroundings in the hospital room. Orienting the client is important but does not address the immediate issue of possible hearing loss, which might be causing the client's behavior.

B. Stand directly in front of the client and ask about any hearing loss. This is the best choice because it addresses the possible reason for the client's behavior directly. Standing in front of the client helps ensure she can see and hear the nurse clearly.

C. Obtain a tuning fork to complete Rinne and Weber tuning fork tests. These tests are useful for diagnosing hearing loss but are not the first step. Initial assessment should involve direct communication to identify the issue.

D. Perform a mental status exam to assess the client's thought processes. While assessing mental status is important, it does not address the immediate observation that the client may have hearing loss.

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Correct Answer is C

Explanation

A. Coronary heart disease. While coronary heart disease can affect overall health, it is not typically associated with changes in nail shape.

B. Recent candida infection. Candida infections can cause nail changes, but they usually result in discoloration and thickening rather than concave curves.

C. Iron deficiency anemia. This is the best choice because iron deficiency anemia is commonly associated with koilonychia (spoon-shaped nails).

D. Diabetes mellitus. Diabetes can cause various changes in skin and nails, but it is not typically associated with brittle, concave nails.

A. Have the client lay flat while listening to the anterior surface of the chest. B. Shave all chest hair that may distort sounds heard through the diaphragm. C. Use the bell of the stethoscope to listen to the lung fields over lower lobes. D. Press the stethoscope's diaphragm firmly on the skin over each lung field.

Correct Answer is D

Explanation

A. Have the client lay flat while listening to the anterior surface of the chest. This position may not allow optimal lung expansion and can cause discomfort, especially in clients with respiratory issues. It is generally better to assess lung sounds with the client in an upright position.

B. Shave all chest hair that may distort sounds heard through the diaphragm. While chest hair can sometimes interfere with sound transmission, shaving is not a practical or necessary step. Pressing the stethoscope firmly can usually mitigate this issue.

C. Use the bell of the stethoscope to listen to the lung fields over lower lobes. The bell is more sensitive to low-pitched sounds, like heart murmurs, and not ideal for lung auscultation. The diaphragm is preferred for assessing lung sounds.

D. Press the stethoscope's diaphragm firmly on the skin over each lung field. This is the best choice because the diaphragm of the stethoscope is more effective at transmitting high-frequency sounds, which are common in lung auscultation. Pressing firmly ensures better contact and clearer sounds.

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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

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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