While taking a history on an older adult male client, his wife reports that he is having increasing periods of short-term memory loss and he occasionally gets confused. How should the nurse proceed with an assessment of the client's sensory system?

Explain the tests to the wife so she can interpret them for her husband.

Assess the client's ability to follow directions before proceeding with the exam.

Defer this part of the exam because the results are likely to be invalid.

Perform the tests because the client's mental status does not affect sensory status.

Answer and Explanation

The Correct Answer is B

A. Explain the tests to the wife so she can interpret them for her husband: While involving family members can be helpful in some situations, it is essential for the client to actively participate in sensory assessments. Having the wife interpret the tests may not give an accurate representation of the client’s sensory capabilities.

B. Assess the client's ability to follow directions before proceeding with the exam: Accurate sensory testing relies on the client's ability to understand and follow instructions, as well as to accurately report sensations. It is important to first evaluate whether the client can understand and follow instructions, as cognitive or memory issues may affect their ability to engage in the sensory exam. This step ensures that the assessment results are valid and reflective of the client’s true sensory function.

C. Defer this part of the exam because the results are likely to be invalid: While cognitive decline can impact the reliability of the exam, it is essential to assess the client's ability to participate and follow instructions before determining whether the sensory exam can be conducted properly. Deferring the exam without evaluation of comprehension is inappropriate.

D. Perform the tests because the client's mental status does not affect sensory status: While mental status may not directly affect the sensory pathways, the ability to follow directions and focus on the exam does influence the accuracy of the assessment. Proceeding without assessing the client's ability to participate could result in inaccurate findings.

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Correct Answer is B

Explanation

A. Guaiac test changes from positive to negative: The guaiac test detects occult blood in stool. A negative result after being positive suggests that the bleeding has stopped, but it does not directly reflect the resolution of bleeding as hematocrit and hemoglobin levels would. While useful for identifying ongoing bleeding, it is not the most reliable indicator of blood volume loss over time.

B. Hematocrit changes from 36% to 32%: A decrease in hematocrit, from 36% to 32%, indicates a loss of red blood cells and suggests that the client’s GI bleeding has not yet resolved. The hematocrit is a direct reflection of blood volume and RBC concentration, so a decline would point to continued blood loss, especially in the setting of GI bleeding.

C. Prothrombin time (PT) changes from 12 seconds to 18 seconds: An increased PT suggests a clotting issue, possibly related to liver dysfunction or anticoagulant therapy. However, PT changes are not a direct indicator of blood loss resolution in the setting of GI bleeding. While it may indicate an issue with coagulation, it is not the best indicator of ongoing blood loss.

D. Hemoglobin A1C changes from 10% to 8%: Hemoglobin A1C is a test for long-term blood glucose control and is unrelated to acute bleeding events. A change in A1C levels would indicate changes in glucose control, not blood loss or resolution of bleeding, making it irrelevant to this scenario.

A. Schedule a follow-up appointment in one month. B. Obtain a dietary consultation for nutrition teaching. C. Instruct the client in the need to use iodized salt. D. Request diagnostic laboratory testing for the client.

Correct Answer is D

Explanation

A. Schedule a follow-up appointment in one month: Delaying evaluation of an enlarged thyroid may result in a missed or late diagnosis of serious conditions such as hyperthyroidism, hypothyroidism, or thyroid nodules. Immediate further assessment is needed rather than waiting.

B. Obtain a dietary consultation for nutrition teaching: While dietary factors, especially iodine deficiency, can contribute to thyroid enlargement, nutritional counseling should follow diagnostic clarification. It is not the first priority when a structural abnormality is found.

C. Instruct the client in the need to use iodized salt: This may be appropriate if iodine deficiency is confirmed, but assuming the cause without testing may lead to inappropriate interventions. Not all goiters are due to iodine deficiency, and some may be caused by autoimmune or neoplastic conditions.

D. Request diagnostic laboratory testing for the client: Ordering thyroid function tests (e.g., TSH, T3, T4) is essential to determine the underlying cause of the enlargement. Depending on these results, further testing like thyroid antibodies or imaging studies (ultrasound, thyroid scan) might be necessary. Laboratory evaluation helps guide further management, whether it is medication, imaging, or referral to endocrinology.

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While taking a history on an older adult male client, his wife reports that he is having increasing periods of short-term memory loss and he occasionally gets confused. How should the nurse proceed with an assessment of the client's sensory system?

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Correct Answer is B

Explanation

When performing a physical assessment, palpation reveals to the clinic nurse that a client has an enlarged thyroid gland. Which action should the nurse take in response to this finding?

Correct Answer is D

Explanation

A client states, "I am legally blind." Which assessment technique should the nurse use to obtain data to support the client's statement?

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