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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Full range of motion bilateral lower extremities: This is a normal finding and indicates the client has the physical strength and mobility to move safely.
B. Hearing acuity intact: Intact senses allow the client to hear alarms, instructions, and environmental cues, reducing injury risk.
C. Ability to use call light: This is a safety factor, as it means the client can summon help when needed.
D. Oriented to person only: A client who is only oriented to person (and not to place, time, or situation) is confused. Confusion is a major risk factor for falls, pulling at tubes, and other accidental injuries.
Correct Answer is ["B","C","E"]
Explanation
A. History of hyperlipidemia: High lipids do not directly impair the physiological process of wound healing.
B. History of diabetes mellitus: Diabetes impairs healing due to decreased vascular perfusion and the fact that high glucose levels inhibit white blood cell function.
C. Prealbumin level: The client’s level (13 mg/dL) is below the normal range (15–36 mg/dL). Prealbumin is the best indicator of acute nutritional status; low levels indicate a protein deficiency necessary for tissue repair.
D. Cholesterol level: While slightly elevated (210 mg/dL), this is a risk for cardiovascular disease, not a primary factor in delayed wound healing.
E. Mini Nutritional Assessment (MNA) score: A score of 7 (out of 14) indicates that the client is malnourished. Nutritional deficits significantly delay the inflammatory and proliferative phases of healing.
F. History of malnutrition: Adequate protein, vitamins (A and C), and zinc are essential for collagen synthesis. A history of malnutrition suggests poor reserves for the healing process.
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