A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
Determine the client's ability to use a communication board.
Provide the teaching without expecting the client to respond.
Avoid the use of facial gestures during the instructions.
Speak with a loud voice while providing the information.
The Correct Answer is A
A. Determine the client's ability to use a communication board.: Expressive aphasia affects the ability to produce language. A communication board allows the client to point to pictures or words, facilitating two-way communication during the teaching process.
B. Provide the teaching without expecting the client to respond.: The nurse must evaluate the client’s understanding (the "teach-back" method) to ensure the information was grasped, even if the response is non-verbal.
C. Avoid the use of facial gestures during the instructions.: Non-verbal cues, gestures, and facial expressions are essential tools to help a client with aphasia understand the context of what is being said.
D. Speak with a loud voice while providing the information.: Aphasia is a language processing disorder, not a hearing impairment. Speaking loudly is unnecessary and can be perceived as patronizing.
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Related Questions
Correct Answer is D
Explanation
A. Notify the charge nurse of the client's condition.: While necessary, it is not the first action in an acute assessment situation.
B. Review the client's most recent SaO2 level in the medical record.: This provides context but does not address the client's current acute respiratory distress.
C. Check the client's medical records to see which medications were recently administered.: This delays immediate intervention for a potentially unstable client.
D. Recheck the client's SaO2 level after having the client cough and clear their throat.: This is a simple, immediate nursing intervention to clear the airway and ensure the reading is accurate and not affected by secretions.
Correct Answer is A
Explanation
A. Brittle hair: Protein-calorie malnutrition often leads to hair that is dull, dry, and brittle, and may eventually fall out (alopecia) due to the lack of nutrients required for hair follicle health.
B. Yellow conjunctivae: This is a sign of jaundice (icterus), usually indicating liver dysfunction or hemolysis, rather than general malnutrition.
C. Clubbing of the fingernails: This is typically a sign of chronic hypoxia (low oxygen levels) associated with cardiac or pulmonary disease, not specifically malnutrition.
D. Bradycardia: While severe starvation can slow the heart rate, tachycardia (a fast heart rate) is a more common finding in the early stages of malnutrition or dehydration.
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