An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?
Over-enunciate word syllables.
Exaggerate nonverbal expressions.
Decrease speaking speed.
Raise voice volume to a shout.
The Correct Answer is C
A. Over-enunciating word syllables can be perceived as patronizing and may not improve understanding for clients with hearing difficulties.
B. Exaggerating nonverbal expressions can help convey meaning, but it does not address the immediate need for clear verbal communication.
C. Decreasing speaking speed allows the client more time to process what is being said, which is particularly important for older adults who may need additional time to understand spoken words.
D. Raising voice volume to a shout may not be necessary and could distort the clarity of speech, making it harder for the client to understand.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While assessing body temperature is important, it is not the most critical action prior to administering vancomycin.
B. Auscultating bowel sounds can provide information about gastrointestinal function but is not specifically required before administering vancomycin.
C. Measuring oxygen saturation is important in assessing respiratory status but is not related to the administration of vancomycin.
D. Checking serum creatinine is essential because vancomycin can affect renal function, and assessing kidney function is critical before administration to prevent potential toxicity, especially in patients with a history of renal impairment.
Correct Answer is D
Explanation
A. Determine the client's last dose of corticosteroids: This may be helpful later in understanding the client's MS management, but it is not the immediate priority in an acute neurological situation.
B. Determine neurological baseline prior to the fall: While important for comparison, establishing the client’s current status through assessment takes priority.
C. Administer a PRN IV antiemetic as prescribed: Vomiting may be a sign of increased intracranial pressure (ICP); treating the symptom without assessing for underlying neurological compromise could delay recognition of a critical condition.
D. Complete head-to-toe neurological assessment: This is the priority. The client’s confusion and projectile vomiting may indicate a traumatic brain injury with increased ICP. Immediate neurological assessment is necessary to identify life-threatening changes and guide urgent interventions.
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