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?

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.