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Which statement indicates to the nurse the client is experiencing some hearing loss?
- A. I clean my ears every day after I take a shower.
- B. I keep turning up the sound on my television.
- C. My ears hurt, especially when I yawn.
- D. I get dizzy when I get up from the chair.
Correct Answer: B
Rationale: Turning up the television volume suggests hearing loss. Ear cleaning is unrelated, ear pain suggests infection, and dizziness indicates vestibular issues.
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Which instruction should the nurse discuss with the client when completing a sensory assessment regarding proprioception?
- A. Instruct the client to lie flat without a pillow during the assessment.
- B. Instruct the client to keep both eyes shut during the assessment.
- C. During the assessment the client must be in a treatment room.
- D. Keep the lights off during the client's sensory assessment.
Correct Answer: B
Rationale: Closing eyes during proprioception testing (e.g., Romberg test) isolates balance to proprioceptive input. Lying flat, treatment rooms, and lights off are irrelevant.
The elderly male client tells the nurse, 'My wife says her cooking hasn't changed, but it is bland and tasteless.' Which response by the nurse is most appropriate?
- A. Would you like me to talk to your wife about her cooking?
- B. Taste buds change with age, which may be why the food seems bland.
- C. This happens because the medications sometimes cause a change in taste.
- D. Why don't you barbecue food on a grill if you don't like your wife's cooking?
Correct Answer: B
Rationale: Age-related taste bud decline reduces taste perception, a common issue in the elderly. Talking to the wife, blaming medications, or suggesting grilling are less appropriate.
The client is a 60-year-old man who had a stapedectomy. He is to ambulate for the first time. Which nursing action should be taken?
- A. Encourage him to walk as far as he comfortably can
- B. Suggest that he practice bending and stretching exercises
- C. Walk with him, holding his arm
- D. Tell him to take deep breaths while he is ambulating
Correct Answer: C
Rationale: Walking with the client and holding his arm ensures safety and prevents falls post-stapedectomy.
Which behavior by the male client should make the nurse suspect the client has a hearing loss? Select all that apply.
- A. The client reports hearing voices in his head.
- B. The client becomes irritable very easily.
- C. The client has difficulty making decisions.
- D. The client’s wife reports he ignores her.
- E. The client does not dominate a conversation.
Correct Answer: B,D,E
Rationale: Irritability, ignoring others, and not dominating conversations suggest hearing loss due to social withdrawal or misunderstanding. Hearing voices is psychiatric, and decision-making is unrelated.
During an assessment, the nurse covers the client's right eye and then observes a shift in the client's gaze after the eye is uncovered. Which conclusion should the nurse make about the results of the test?
- A. The client has opacity of the lens.
- B. The client has absence of the blink reflex.
- C. The client has increased intraocular pressure.
- D. The client has weakness in the extraocular muscles.
Correct Answer: D
Rationale: Covering and then uncovering the client's eye and then observing for a shift in the client's gaze is the cover-uncover test used to detect weakness in the extraocular muscles. Lens opacity is detected by direct observation. Stroking the eyelashes will evoke the blink reflex. The intraocular pressure is measured by tonometry.