The nurse suspects that the client has a hearing disorder; however, the client denies not being able to hear. What initial action should the nurse take to assess the client's hearing?
1. Schedule a Weber and Rinne test
2. Observe the client's interaction with family
3. Use an otoscope to visualize the inner ear
4. Confront the client with the suspicion
2. Observe the client's interaction with family
Rationale:
The most telling of these options would be to observe the client's interactions with family. The nurse should assess for frequent requests to repeat, inattention to conversation, turning one ear to the conversation, and lip-reading. The Weber and Rinne test and use of an otoscope may be a part of an assessment but will not yield as much information as simple observation. The client has already denied having a hearing problem, so confronting the client with the nurse's suspicion will probably only alienate the client from the nurse.
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