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 ["A","B","C","D"]

Explanation

A. Peripheral edema: Peripheral edema is a classic sign of right-sided heart failure due to venous congestion. When the heart cannot pump effectively, there is increased fluid volume and pressure in the veins causing fluid to leak into the surrounding tissues fluid accumulates in dependent areas like the legs and ankles, especially in older adults with chronic heart failure.

B. Dyspnea: Dyspnea is a key indicator of left-sided heart failure, resulting from pulmonary congestion. As the left ventricle fails to pump efficiently, fluid backs up into the lungs, impairing gas exchange and causing shortness of breath during exertion or even at rest. Dyspnea can occur at rest or with exertion and may worsen when lying flat (orthopnea) or during the night (paroxysmal nocturnal dyspnea).

C. Jugular venous distension: JVD occurs when elevated right atrial pressure causes the jugular veins to become distended. It is a significant clinical finding in right-sided heart failure and reflects systemic fluid overload and impaired venous return.

D. Intercostal retractions: Intercostal retractions are a sign of increased respiratory effort, indicating that the patient is struggling to breathe. In heart failure exacerbation, pulmonary congestion increases the work of breathing, leading to respiratory distress and visible use of accessory muscles.

E. Headaches: Headaches are not typically associated with heart failure and are not considered a reliable indicator of an exacerbation. They may be due to other causes such as hypertension, stress, or neurological issues and require separate evaluation.

A. Urinary frequency, unsteady gait, dental enamel erosion. B. Breast tenderness, tremors, high blood pressure. C. Vaginal discharge, presence of genital warts, abdominal tenderness. D. Body weight, hirsutism, thyroid enlargement.

Correct Answer is D

Explanation

A. Urinary frequency, unsteady gait, dental enamel erosion: These findings may suggest a urinary tract infection, neurological issue, or an eating disorder like bulimia. However, none are directly linked to amenorrhea in the context of a negative pregnancy test and recent missed periods.

B. Breast tenderness, tremors, high blood pressure: These symptoms could suggest hyperthyroidism or hormonal imbalance, but they are less specific to the cause of missed periods in this scenario compared to more directly relevant signs like weight or thyroid size.

C. Vaginal discharge, presence of genital warts, abdominal tenderness: These findings are related to sexually transmitted infections or gynecologic conditions, but the client has not had recent intercourse, and her main concern is amenorrhea, making these findings less relevant.

D. Body weight, hirsutism, thyroid enlargement: These are key assessment points when evaluating causes of amenorrhea. Low or high body weight can disrupt hormonal balance, hirsutism may indicate polycystic ovary syndrome (PCOS), and thyroid enlargement could suggest a thyroid disorder both common causes of menstrual irregularities in young women.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm(s) to the nurse that the client is experiencing an exacerbation of the HF? Select all that apply.

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

Explanation

Correct Answer is D

Explanation

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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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