An older adult client is hospitalized with a fractured femur. During a routine nursing assessment, the client repeatedly asks the nurse to "speak up" so that the client can hear the questions. Which action is best for the nurse to take?
Raise voice volume to a shout.
Exaggerate nonverbal expressions.
Decrease speaking speed.
Over-enunciate word syllables.
The Correct Answer is D
A. Raising the voice volume to a shout can be startling for the client and may come across as aggressive or disrespectful.
B. Exaggerating nonverbal expressions might not effectively address the client's difficulty in hearing. While nonverbal communication is essential, especially for older adults with hearing impairments, exaggerating gestures may not necessarily improve communication clarity.
C. Speaking more slowly can help the client better understand what is being said without the nurse needing to shout, which might cause discomfort or further confusion.
D. Over-enunciating or exaggerating expressions can appear patronizing, and shouting can be distressing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Vancomycin is primarily excreted by the kidneys, and monitoring serum creatinine levels helps assess renal function. Impaired renal function can affect vancomycin clearance and increase the risk of toxicity.
A. Measuring oxygen saturation is not directly related to the administration of vancomycin for Clostridium difficile infection.
B. Assessing body temperature may not be the most pertinent action before administering vancomycin for Clostridium difficile infection.
C. Auscultating bowel sounds is also not directly related to the administration of vancomycin for Clostridium difficile infection.
Correct Answer is ["B","D","F"]
Explanation
B. Encourage the client to take breaks from the oxygen mask every few hours: While supplemental oxygen may be necessary for clients with pneumonia who are hypoxemic, encouraging periodic breaks from the oxygen mask allows the client to mobilize and promote lung expansion, which can improve ventilation and oxygenation.
D. Ambulation helps prevent complications such as pneumonia-associated atelectasis by promoting lung expansion and mobilizing respiratory secretions. However, it's essential to ensure that ambulation is safe and appropriate based on the client's condition and mobility status.
F. Elevating the head of the bed promotes optimal lung expansion, reduces the work of breathing, and helps improve oxygenation in clients with pneumonia. This position also facilitates drainage of respiratory secretions and decreases the risk of aspiration.
A. Fever is often a sign of infection and can increase metabolic demand and oxygen consumption. Treating fever with antipyretics helps reduce metabolic demand, discomfort, and respiratory distress, thereby potentially improving ventilation and oxygenation.
C. Suctioning may be necessary to remove respiratory secretions in clients with pneumonia who are unable to clear their airways effectively. However, routine suctioning should be avoided unless clinically indicated, as it may cause discomfort and irritation to the airways.
E. Quick, shallow breaths (hyperventilation) can lead to respiratory alkalosis and impair oxygenation. Instead, clients with pneumonia should be encouraged to breathe slowly and deeply to promote effective gas exchange and lung expansion.
G. Teaching the client to cough at least once an hour: While coughing can help clear respiratory secretions and improve ventilation in clients with pneumonia, coughing excessively or unnecessarily may cause fatigue and discomfort. Clients should be encouraged to cough as needed to clear secretions but not excessively.
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