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.”. Which action is best for the nurse to take?
Decrease speaking speed.
Over-enunciate word syllables.
Raise voice volume to a shout.
Exaggerate nonverbal expressions.
The Correct Answer is B
Choice A rationale
Decreasing speaking speed may help with clarity, but it does not address the issue of hearing loss.
Choice B rationale
Over-enunciating word syllables can help the client understand speech better, especially if they have hearing difficulties. This technique makes it easier for the client to read lips and understand spoken words.
Choice C rationale
Raising voice volume to a shout can be uncomfortable and may not improve understanding. It can also be perceived as rude or aggressive.
Choice D rationale
Exaggerating nonverbal expressions may help with communication, but it is not as effective as over-enunciating word syllables for clients with hearing difficulties.
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Correct Answer is B
Explanation
Choice A rationale
Teaching anxiety reduction methods for feelings of suffocation is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice B rationale
Increasing the daily intake of oral fluids to liquefy secretions is the most important action for the nurse to instruct the client about self-care. This helps to thin the mucus, making it easier to expectorate and improving breathing.
Choice C rationale
Calling the clinic if undesirable side effects of medications occur is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice D rationale
Avoiding crowded enclosed areas to reduce pathogen exposure is important but not the most immediate action needed to address the client’s respiratory symptoms.
Correct Answer is C
Explanation
Choice A rationale
Offering mouthwash for thorough cleansing after brushing teeth can be too harsh for clients with painful mouth ulcers caused by Candida albicans. It may cause further irritation and discomfort.
Choice B rationale
While assistive personnel can help with personal care, oral care should not be left solely to the nurse. Providing appropriate tools and guidance for the client to perform oral care is essential.
Choice C rationale
Providing a soft-bristled toothbrush is appropriate for clients with oral Candida albicans. It helps in gentle cleaning without causing additional pain or damage to the mucosa.
Choice D rationale
Wearing sterile gloves is not necessary for routine oral care. Clean gloves are sufficient unless there is a specific need for sterility, such as in surgical procedures.