a nurse is caring for a client who has global aphasia both receptive and expressive which of the following should the nurse not include in the clients
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Nursing Elites

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1. A client has global aphasia affecting both receptive and expressive language abilities. Which intervention should NOT be included in the client's care plan?

Correct answer: C

Rationale: Individuals with global aphasia have difficulty understanding and expressing language. Speaking loudly may not improve comprehension and can be perceived as aggressive. Therefore, it is important not to speak loudly to a client with global aphasia. Speaking at a slower rate, using visual aids like flash cards, and breaking down instructions into simple steps can facilitate communication and understanding for the client.

2. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?

Correct answer: D

Rationale: Chest physiotherapy is the most effective intervention in cases of impaired gas exchange related to increased secretions. This technique helps mobilize and clear secretions from the airways, thereby improving gas exchange in the lungs. Placing a humidifier or administering oxygen by high humidity face mask may provide moisture but may not directly address the clearance of secretions. Encouraging increased fluid intake can help with hydration but may not address the underlying issue of impaired gas exchange due to secretions.

3. Which of the following is the correct meaning of CBR?

Correct answer: C

Rationale: In medical terminology, 'CBR' stands for Complete Bed Rest. This term indicates the necessity for a patient to remain in bed without engaging in any physical activities beyond what is essential for daily living, to aid in the recovery process or to prevent further health complications. Choices A, B, and D are incorrect as they do not reflect the medical meaning of CBR.

4. A client with tuberculosis is receiving a new prescription for isoniazid (INH). The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?

Correct answer: C

Rationale: Tingling of the hands is a common adverse effect of isoniazid (INH) due to its potential to cause peripheral neuropathy. This sensation can be an early sign of nerve damage, and thus, the client should be instructed to report it promptly to the healthcare provider for further evaluation and management.

5. Which of the following actions will most likely lead to a break in the sterile technique for respiratory isolation?

Correct answer: D

Rationale: Failure to wear gloves during a bed bath can potentially introduce pathogens, compromising the sterile technique necessary for respiratory isolation. Proper hand hygiene and personal protective equipment are crucial to prevent the transmission of infectious agents in such settings.

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