An older adult 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?

Raise voice volume to a shout

Over-enunciate word syllables

Decrease speaking speed

Exaggerate nonverbal expressions

Answer and Explanation

The Correct Answer is C

Choice A reason: Shouting increases volume but may distort speech, worsening comprehension for an older adult with hearing loss. Age-related presbycusis impairs high-frequency sound perception, and shouting can cause discomfort without improving clarity, making this an ineffective communication strategy for the client.

Choice B reason: Over-enunciating syllables may help slightly but can sound unnatural, confusing the client. It does not address the primary issue of processing speed in age-related hearing loss, where slower speech allows better auditory processing, making this less effective than reducing speaking speed.

Choice C reason: Decreasing speaking speed is best, as presbycusis slows auditory processing in older adults. Slower speech allows the client to process sounds clearly, improving comprehension without distortion, addressing the client’s difficulty hearing questions effectively and enhancing communication during the assessment.

Choice D reason: Exaggerating nonverbal expressions aids visual cues but does not address auditory comprehension. Hearing loss requires auditory adjustments, and nonverbal cues alone are insufficient for understanding spoken questions, making this less effective than slowing speech to improve verbal clarity.

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Correct Answer is B

Explanation

Choice A reason: Clay-colored stool indicates bile duct obstruction, not directly related to esophageal varices in cirrhosis. Varices are dilated veins prone to rupture, and while liver dysfunction affects bile, hematemesis is a more immediate, life-threatening complication, making this choice less critical.

Choice B reason: Hematemesis is critical to monitor, as esophageal varices in cirrhosis are fragile, dilated veins that can rupture, causing massive upper gastrointestinal bleeding. This leads to life-threatening hemorrhage, requiring urgent intervention, making it the priority due to its high mortality risk in portal hypertension.

Choice C reason: Anorexia is common in cirrhosis due to metabolic changes but is not specific to varices. While it affects nutrition, it is less urgent than hematemesis, which indicates variceal bleeding, a medical emergency, making this choice secondary to bleeding risk.

Choice D reason: Brown, foamy urine suggests renal issues, like proteinuria, not directly linked to esophageal varices. Variceal bleeding is a more immediate threat in cirrhosis, as urine changes are unrelated to portal hypertension’s acute complications, making this choice less critical.

A. Unexplained weight loss B. Trouble sleeping C. Difficulty with urination D. Recent oral intake

Correct Answer is C

Explanation

Choice A reason: Unexplained weight loss is not directly relevant to pyridostigmine administration. Myasthenia gravis affects neuromuscular junctions, and pyridostigmine enhances acetylcholine, improving muscle strength. Weight loss may indicate systemic issues, but it does not affect the drug’s immediate safety or efficacy, making this choice secondary.

Choice B reason: Trouble sleeping is unrelated to pyridostigmine’s administration. The drug targets acetylcholinesterase, increasing muscle strength in myasthenia gravis, but does not typically affect sleep. Insomnia may reflect other conditions, but it is not a critical pre-administration concern compared to cholinergic side effects.

Choice C reason: Difficulty with urination is critical, as pyridostigmine’s cholinergic effects can exacerbate urinary retention by stimulating bladder smooth muscle. In myasthenia gravis, this may worsen existing autonomic dysfunction, risking complications like infection, making this the most important information to assess before administration.

Choice D reason: Recent oral intake is relevant for gastrointestinal side effects, as pyridostigmine may cause nausea, but it is less critical than urinary issues. Taking the drug with food can mitigate nausea, but urinary retention poses a greater immediate risk, making this choice secondary.

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An older adult 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

Correct Answer is B

Explanation

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?

Correct Answer is C

Explanation

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

An older adult 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?

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