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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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. Which of the following is not a cause of tachycardia?

Correct answer: D

Rationale: Tachycardia is an increased heart rate, and it can be caused by various factors such as fever, exercise, and sympathetic nervous system stimulation, all of which tend to increase heart rate. However, parasympathetic nervous system stimulation typically slows the heart rate, making it the exception among the choices provided. Thus, parasympathetic nervous system stimulation is not a cause of tachycardia.

3. Which of the following clusters of data belong to Maslow’s hierarchy of needs?

Correct answer: D

Rationale: Maslow's hierarchy of needs is a theory in psychology that categorizes human needs into five levels: physiological needs, safety needs, love and belongingness, esteem needs, and self-actualization. 'Love and belonging' corresponds to the third level, 'Physiological needs' to the first level, and 'Self-actualization' to the highest level. Therefore, all the clusters listed in the choices are part of Maslow's hierarchy of needs. Selecting 'All of the above' (option D) is the correct answer as it includes all the clusters associated with Maslow's theory.

4. A client is being cared for by a nurse 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer?

Correct answer: D

Rationale: The client's presentation with an SaO2 of 91%, audible wheezes, and use of accessory muscles indicates respiratory distress, likely due to bronchoconstriction. Beta2 agonists are the appropriate class of medications to administer in this situation as they act as bronchodilators, helping to relieve the bronchoconstriction and improve airflow to the lungs. Antibiotics, beta-blockers, and antivirals are not indicated for this client's respiratory distress symptoms.

5. What is a muscular enlarged pouch or sac that lies slightly to the left and is used for the temporary storage of food?

Correct answer: C

Rationale: The correct answer is the stomach. The stomach is a muscular organ located slightly to the left in the abdominal cavity. It serves as a temporary storage site for food where it is mixed with digestive enzymes and acids to begin the process of digestion. The gallbladder (Choice A) is not involved in food storage; it stores bile produced by the liver. The urinary bladder (Choice B) is part of the urinary system and stores urine. The lungs (Choice D) are responsible for respiration, not food storage.

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