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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Observing for edema around the ankles is important but not the most critical assessment related to hydromorphone use.
B. Auscultating the client's bowel sounds is crucial because opioids like hydromorphone can lead to decreased gastrointestinal motility and potential constipation or bowel obstruction.
C. Measuring the client's capillary glucose level is important for clients with diabetes but not directly related to the effects of hydromorphone.
D. Counting the apical and radial pulses simultaneously is important for assessing cardiovascular health but does not specifically relate to the side effects of opioid administration.

A. Clay-colored stool. B. Brown, foamy urine. C. Hematemesis. D. Anorexia.

Correct Answer is C

Explanation

A. Clay-colored stool can indicate bile duct obstruction but is not the immediate concern with esophageal varices.
B. Brown, foamy urine may suggest liver dysfunction but does not pose an immediate life threat like variceal bleeding.
C. Hematemesis, or vomiting blood, is a critical complication of esophageal varices due to the risk of significant hemorrhage and requires immediate intervention.
D. Anorexia can occur in cirrhosis but is not as urgent as monitoring for potential bleeding from varices.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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