Nokea
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.
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The client is receiving discharge teaching for a new prescription of phenelzine. The nurse should instruct the client that it is not safe to eat which of the following foods while taking this medication?
- A. whole grain bread
- B. Avocados
- C. Smoked salmon
- D. Pepperoni pizza
Correct Answer: B
Rationale: Avocados contain high levels of tyramine, which can cause a hypertensive crisis when consumed with phenelzine, a monoamine oxidase inhibitor (MAOI). It is essential for clients taking MAOIs to avoid foods rich in tyramine to prevent dangerous interactions and potential health risks.
A healthcare provider is preparing to care for a client following chest tube placement. Which of the following items should NOT be available in the client's room?
- A. Oxygen
- B. Sterile water
- C. Enclosed hemostat clamps
- D. Indwelling urinary catheter
Correct Answer: D
Rationale: Following chest tube placement, an indwelling urinary catheter is not typically needed or relevant to the care provided. Chest tube placement is primarily concerned with managing pleural effusion or pneumothorax, and urinary catheterization is not directly related to this procedure. Oxygen, sterile water, and enclosed hemostat clamps are commonly used items in the care of a client with a chest tube in place, to ensure proper oxygenation, maintain drainage system integrity, and manage any bleeding that may occur. Therefore, the indwelling urinary catheter should not be available in the client's room following chest tube placement.
A healthcare professional is monitoring a group of clients for increased risk of developing pneumonia. Which of the following clients should the healthcare professional NOT expect to be at risk?
- A. Client who has dysphagia
- B. Client who has AIDS
- C. Client who was vaccinated for pneumococcus and influenza 6 months ago
- D. Client who has a closed head injury and is receiving ventilation
Correct Answer: C
Rationale: A client who was vaccinated for pneumococcus and influenza 6 months ago would have a reduced risk of developing pneumonia compared to those who have not been vaccinated. Vaccination helps protect individuals from specific pathogens, thereby lowering the risk of infection. Clients with dysphagia, AIDS, or a closed head injury and receiving ventilation are at higher risk for pneumonia due to compromised immunity, respiratory function, or protective airway reflexes, respectively.
While caring for a client in a clinic, a healthcare professional learns that the client woke up not recognizing their partner, surroundings, has chills, and chest pain worsening upon inspiration. What should be the healthcare professional's priority action?
- A. Obtain baseline vital signs and oxygen saturation.
- B. Obtain a sputum culture.
- C. Obtain a complete history from the client.
- D. Provide a pneumococcal vaccine.
Correct Answer: A
Rationale: The priority action for the healthcare professional is to obtain the client's baseline vital signs and oxygen saturation. This will provide essential information on the client's current physiological status and help guide further assessment and intervention. Assessing the vital signs and oxygen saturation can help identify any immediate concerns like hypoxia or sepsis, which require prompt attention. While obtaining a complete history and considering a pneumococcal vaccine may be important in the overall care of the client, assessing the vital signs and oxygen saturation takes precedence to address the client's immediate physiological needs.
Prior to a thoracentesis, which of the following actions should the nurse take?
- A. Position the client in an upright position, leaning over the bedside table.
- B. Explain the procedure.
- C. Obtain ABGs.
- D. Administer benzocaine spray.
Correct Answer: A
Rationale: Positioning the client in an upright position, leaning over the bedside table helps to facilitate access to the thoracic cavity during the thoracentesis procedure. This position allows for easier identification and access to the insertion site. Explaining the procedure to the client is important, but positioning is the priority. Obtaining ABGs is not directly related to the thoracentesis procedure. Administering benzocaine spray is not a standard practice before a thoracentesis.