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.
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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Correct Answer is B
Explanation
Choice A rationale
A translucent, pearly gray, and mobile tympanic membrane is a normal finding and does not align with the symptoms of itching, pain, and discharge.
Choice B rationale
A red, edematous ear canal with no visualization of the tympanic membrane is indicative of otitis externa, commonly known as “swimmer’s ear.”. This condition is characterized by inflammation and infection of the external ear canal, often following swimming.
Choice C rationale
A thickened and bulging tympanic membrane is more indicative of otitis media with effusion or acute otitis media, where fluid or pus collects behind the eardrum.
Choice D rationale
A retracted and non-mobile tympanic membrane is typically associated with eustachian tube dysfunction or negative middle ear pressure, not with the symptoms described.
Correct Answer is B
Explanation
Choice A rationale
The description of pulse volume (4+ and 0) is not appropriate for documenting a bruit. A bruit is an abnormal sound heard over an artery, indicating turbulent blood flow, not pulse volume.
Choice B rationale
A bruit is an abnormal sound heard over an artery due to turbulent blood flow, often caused by atherosclerosis. The presence of a bruit in the left carotid artery and the absence of sound in the right carotid artery should be documented as such.
Choice C rationale
While a bruit can indicate partial occlusion of an artery, it does not confirm complete occlusion. Complete occlusion would typically result in the absence of blood flow and no sound. Therefore, this choice is incorrect.
Choice D rationale
The presence of a bruit does not necessarily indicate a strong pulse. It indicates turbulent blood flow, which is often due to narrowing or partial blockage of the artery. This choice is incorrect