A female client with aphasia is trying to verbalize feelings to the nurse and states, "I want...," but does not finish the statement. How should the nurse respond to this unfinished statement?
Offer the client to move to a quiet room first.
Allow the client time to complete her sentence.
Pull up a chair and sit quietly with the client.
Provide a list of phrases to express her-self properly.
The Correct Answer is B
A. Offer the client to move to a quiet room first: Changing the environment may reduce distractions, but it does not directly support the client’s immediate attempt to communicate. The priority is to respond to the client’s active effort to speak in the moment.
B. Allow the client time to complete her sentence: Allowing extra time promotes autonomy, reduces frustration, and respects the communication process for clients with aphasia. It gives the client space to formulate thoughts without pressure or interruption, which supports language recovery and expression.
C. Pull up a chair and sit quietly with the client: Sitting quietly can offer emotional support, but it may be perceived as passive when the client is actively trying to communicate. The nurse should take a facilitative role by giving the client time to speak, rather than only offering silent presence.
D. Provide a list of phrases to express herself properly: Providing phrases may overwhelm or confuse the client, especially during spontaneous attempts to speak. Aphasia affects word retrieval, and prompting with choices may interrupt the client's cognitive effort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Ask the client if she has any alcohol in the room at this time: This is an essential step in assessing for immediate safety and contraband that may impact her treatment plan, especially considering her symptoms and possible withdrawal risk.
B. Administer a PRN prescription for an antianxiety drug: This could mask symptoms of alcohol withdrawal or interact negatively with alcohol. Medication should be given only after thorough assessment and consultation.
C. Inform the family that they are enabling the client: While family education is important, using accusatory language like "enabling" can damage therapeutic relationships. A nonjudgmental, supportive approach is better.
D. Observe for signs to determine if client is inebriated: Monitoring for inebriation supports accurate clinical assessment and decisions about withdrawal protocols, safety, and medication timing.
E. Schedule a conference with the client and family members: A joint meeting allows open discussion, identifies care goals, and promotes understanding and support from all parties involved.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Rationale:
- Respirations: After administering morphine, it is crucial to monitor the client's respirations because opioids can cause respiratory depression, which may be more pronounced in elderly patients or those who are in pain and immobile.
- Deep breathing techniques: The nurse should encourage deep breathing techniques. This helps improve lung expansion and reduces the risk of respiratory complications such as pneumonia and atelectasis, especially in a client with decreased mobility due to pain and injury.
Rationale for Incorrect Options:
- Heart rate: While heart rate monitoring is important, it is not the primary concern immediately after morphine administration. The client's respiratory status takes precedence, especially considering the risk of opioid-induced respiratory depression.
- Blood pressure: While blood pressure monitoring is essential, morphine administration primarily affects the respiratory system, not the circulatory system. The nurse should prioritize respiratory monitoring over blood pressure unless the patient exhibits signs of hypotension.
- Range of motion exercises: Range of motion exercises are important for mobility and rehabilitation, but they are not a priority immediately following the trauma and morphine administration. The client should be assessed and stabilized before beginning exercises.
- Joint protection techniques: Joint protection techniques are beneficial in long-term rehabilitation, but in the acute phase, the priority is to manage the fracture, pain, and prevent further complications.
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