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

ATI RN

ATI Fundamentals

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?

A. Speak to the client at a slower rate.
B. Assist the client in using flash cards with pictures.
C. Speak to the client in a loud voice.
D. Give instructions one step at a time.

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. A client with fibromyalgia requests pain medication. Which of the following medications should the nurse administer?

A. Pregabalin
B. Lorazepam
C. Colchicine
D. Codeine

Correct answer: A

Rationale: Pregabalin is commonly used to manage pain associated with fibromyalgia. It works by reducing the number of pain signals sent out by damaged nerves. Lorazepam is a benzodiazepine used for anxiety, not pain management. Colchicine is primarily used for gout treatment, and codeine, while an analgesic, is not typically the first-line choice for fibromyalgia pain due to its potential for side effects and misuse.

3. During a seizure, what is the primary intervention?

A. Protect the patient from injury
B. Insert an airway
C. Elevate the head of the bed
D. Withdraw all pain medications

Correct answer: A

Rationale: The primary intervention during a seizure is to protect the patient from injury. This involves creating a safe environment by moving harmful objects away, cushioning the head, and staying with the patient until the seizure ends. Inserting an airway is only necessary if the patient's airway is obstructed, not routinely during a seizure. Elevating the head of the bed is not a priority during an active seizure as it won't affect the seizure's outcome. Withdrawing all pain medications is not a standard practice unless there are specific contraindications related to the seizure itself.

4. What is the correct sequence for assessing the abdomen?

A. Tympanic percussion, measurement of abdominal girth, and inspection
B. Assessment for distention, tenderness, and discoloration around the umbilicus
C. Percussion, palpation, and auscultation
D. Auscultation, percussion, and palpation

Correct answer: D

Rationale: The correct sequence for assessing the abdomen is auscultation, percussion, and palpation. Auscultation allows the healthcare provider to listen for bowel sounds, followed by percussion to assess for areas of tenderness or abnormal distention, and finally palpation to feel for masses or organ enlargement. This sequence ensures a systematic and thorough assessment of the abdomen.

5. If a patient's blood pressure is 150/96, what is his pulse pressure?

A. 54
B. 96
C. 150
D. 246

Correct answer: A

Rationale: Pulse pressure is calculated by subtracting the diastolic pressure from the systolic pressure. In this case, the systolic pressure is 150 and the diastolic pressure is 96. Therefore, the pulse pressure is 150 - 96 = 54. Pulse pressure represents the force generated by the heart with each contraction and is an important indicator of cardiovascular health.