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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?

 

A.

Begin to orient the client to her surroundings in the hospital room.

B.

Stand directly in front of the client and ask about any hearing loss.

C.

Obtain a tuning fork to complete Rinne and Weber tuning fork tests.

D.

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

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

Orienting the client to her surroundings is important but does not address the immediate issue of potential hearing impairment, which may be causing communication difficulties.

 

Choice B rationale

 

Standing directly in front of the client and asking about any hearing loss is the first action to take. The client’s behavior of ignoring questions and speaking loudly to her son suggests a potential hearing impairment. Addressing this issue first can help improve communication and ensure the client understands the nurse’s questions.

 

Choice C rationale

 

Obtaining a tuning fork to complete Rinne and Weber tuning fork tests is appropriate for assessing hearing acuity but should be done after initially addressing the potential hearing loss through direct questioning.

 

Choice D rationale

 

Performing a mental status exam to assess the client’s thought processes is important but should be done after addressing the potential hearing impairment, which may be the primary cause of the observed behavior.


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View Related questions

Correct Answer is C

Explanation

Choice A rationale

Painful symptoms alleviated by warmth are more indicative of conditions such as arthritis or muscle strain rather than venous insufficiency.

Choice B rationale

Cool, pale skin below the knees is more indicative of arterial insufficiency rather than venous insufficiency.

Choice C rationale

Decreased pain when legs are elevated is a common symptom of venous insufficiency. Elevating the legs helps reduce venous pressure and alleviate symptoms such as swelling and aching.

Choice D rationale

Deep, continuous pain in the calf muscles is more indicative of conditions such as deep vein thrombosis (DVT) rather than venous insufficiency.

Correct Answer is B

Explanation

Choice A rationale

A 75-year-old with a pneumothorax and a chest tube may have a displaced PMI due to the pneumothorax, but it is not necessarily difficult to locate. The chest tube may also cause some displacement, but it is not the primary factor affecting PMI location.

Choice B rationale

A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg) is likely to have difficulty locating the PMI due to the increased adipose tissue. Obesity can make it challenging to palpate the PMI as the excess tissue can obscure the heart’s apex.

Choice C rationale

A 2-year-old who is demonstrating diaphragmatic breathing may have a PMI that is slightly higher and more medial than in adults, but it is generally not difficult to locate.

Choice D rationale

A 45-year-old long-distance runner with a body mass index (BMI) of 18 kg/m² is likely to have a more prominent PMI due to a leaner body composition and a potentially enlarged heart from athletic conditioning.

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