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 A
Explanation
Choice A rationale
Observing pupil size when focusing on a near object and then a far object assesses the accommodation reflex. This reflex involves the pupils constricting when focusing on a near object and dilating when focusing on a far object. This response is mediated by the parasympathetic nervous system and is a normal physiological reaction to changes in focal distance.
Choice B rationale
Determining if dilation of the pupils occurs when the room is darkened assesses the pupillary light reflex, not accommodation. The pupillary light reflex involves the pupils dilating in low light conditions to allow more light to enter the eye, which is controlled by the sympathetic nervous system.
Choice C rationale
Noting the speed of pupil constriction when a penlight is shined into the eye assesses the direct and consensual light reflexes. This test evaluates the function of the optic and oculomotor nerves and is not related to the accommodation reflex.
Choice D rationale
Comparing the shape of each of the pupils bilaterally with normal room light assesses for anisocoria or differences in pupil size, which can indicate neurological issues. This assessment does not evaluate the accommodation reflex.
Correct Answer is B
Explanation
Choice A rationale
Sorting a collection of socks may assess cognitive function and fine motor skills, but it does not directly evaluate the ability to perform activities of daily living (ADL) such as bathing, dressing, or feeding.
Choice B rationale
Opening a bar soap package is a practical task that requires fine motor skills and dexterity, which are essential for performing activities of daily living (ADL) such as bathing and grooming.
Choice C rationale
Telephoning a family member assesses communication skills and cognitive function but does not directly evaluate the ability to perform activities of daily living (ADL).
Choice D rationale
Reading a short paragraph assesses cognitive function and literacy skills but does not directly evaluate the ability to perform activities of daily living (ADL).