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Assessment for PAD includes :-

HEART: decreased peripheral

pulses

DERM: cool shiny skin, hair loss,

ulcers, gangrene, impaired

sensation

MISC.: intermittent claudication

S: shiney skin

H: hair loss to the extremity

I: intermittent claudication

N: nasty ulcers

E: extremities will be cool

 

Causes of PAD includes Causes:

❖ Arteriosclerosis

❖ Raynauds

❖ Buerger’s

❖ Smoking

❖ Diabetes

❖ Hyperlipidemia

❖ Hypertension

❖ Obesity

❖ Sedentary lifestyle

❖ Age

 

Nursing interventions for PAD includes :-

❖ Check extremities for

paleness, coolness or

necrosis

❖ Meticulous foot care: warm

water, gently dry

thoroughly, use lubricants,

wear clean cotton socks

❖ Do not cross legs

❖ Regular exercise

❖ No smoking

❖ Weight loss

Nursing Teaching for PAD includes:-

❖ Educate the client to

maintain aseptic technique.

❖ Instruct the client on how

to administer IV antibiotics.

❖ Have the client record

temp daily for six weeks.

❖ Encourage oral hygeine for

six weeks with a soft bristle

toothbrush 2x daily.

❖ Have the client clean any

skin lacerations and apply

antibiotic ointment.

❖ Client should inform all

HCP’s of hx of

endocarditis.

❖ Client should use

prophylactic antibiotics for

oral procedures.

❖ Tech the client the signs

and symptoms of emboli

and HF.

 

Medical treatment for PAD includes:-

❖ Arterial bypass with

autogenous vein or

synthetic graft.

❖ Endarterectomy.

❖ Patch graft angioplasty.

❖ Amputation. Typing Service – Picture Document to Word Document

 

 

A patient is being discharged following insertion of a permanent pacemaker. The nurse determines that the patient requires further instruction on safety precaution after the following statement:

Overview

A new pacemaker requires limitation of physical activity, including no lifting, pulling, or pushing more than 5 pounds, so the patient will need to be educated further if they speak of lifting something greater than 5 pounds.

 

Learning Outcomes

A new pacemaker requires limitation of physical activity, including no lifting, pulling, or pushing more than 5 pounds. Other limitations include limiting tasks like sweeping in repetitive motions, keeping the area free from pressure (such as tight clothing or suspenders), and not raising the arm on the affected side above the level of the heart for the first few weeks. The pacemaker insertion site may be bruised, swollen, tender, and instructions may include gentle washing of incision site, and not applying lotion or powder.

 

 

 

Heparin

 

64. A client with atrial fibrillation who is receiving maintenance therapy of

warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of

these laboratory values, the nurse anticipates which prescription?

1. Adding a dose of heparin sodium

2. Holding the next dose of warfarin

3. Increasing the next dose of warfarin

4. Administering the next dose of warfarin

64. Answer: 2

Rationale: The normal PT is 11 to 12.5 seconds (conventional therapy and SI

units). A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because

the value of 35 seconds is high, the nurse should anticipate that the client would not

receive further doses at this time. Therefore, the prescriptions noted in the remaining

options are incorrect

 

68. A client is receiving a continuous intravenous infusion of heparin sodium to

treat deep vein thrombosis. The client’s activated partial thromboplastin time

(aPTT) is 65 seconds. The nurse anticipates that which action is needed?

1. Discontinuing the heparin infusion

2. Increasing the rate of the heparin infusion

3. Decreasing the rate of the heparin infusion

4. Leaving the rate of the heparin infusion as is

68. Answer: 4

Rationale: The normal aPTT varies between 30 and 40 seconds (30 and 40

seconds), depending on the type of activator used in testing. The therapeutic dose of

heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 (45 to

60) and 2.5 (75 to 100) times normal. This means that the client’s value should not be

less than 45 seconds or greater than 100 seconds. Thus, the client’s aPTT is within the

therapeutic range and the dose should remain unchanged.

Test-Taking Strategy: Focus on the subject, the expected aPTT for a client

receiving a heparin sodium infusion. Remember that the normal range is 30 to 40

seconds and that the aPTT should be between 1.5 and 2.5 times normal when the

client is receiving heparin therapy. Simple multiplication of 1.5 and 2.5 by 30 and 40

will yield a range of 45 to 100 seconds. This client’s value is 65 seconds.

 

 

Activated partial thromboplastin time (aPTT)

1. The aPTT evaluates how well the coagulation

sequence (intrinsic clotting system) is functioning by

measuring the amount of time it takes in seconds for

recalcified citrated plasma to clot after partial

thromboplastin is added to it.

2. The test screens for deficiencies and inhibitors of all

factors, except factors VII and XIII.

3. Usually, the aPTT is used to monitor the

effectiveness of heparin therapy and screen for

4. Normal reference interval: 30 to 40 seconds

(conventional and SI units [International System of

Units]), depending on the type of activator used.

5. If the client is receiving intermittent heparin therapy,

draw the blood sample 1 hour before the next

scheduled dose.

6. Do not draw samples from an arm into which heparin

is infusing.

7. Transport specimen to the laboratory immediately.

8. Provide direct pressure to the venipuncture site for 3

to 5 minutes.

9. The aPTT should be between 1.5 and 2.5 times normal

when the client is receiving heparin therapy.

10. Elevated values occur in the following: Deficiency of

one or more of the following: factor I, II, V, or VIII;

factors IX and X; factor XI; and factor XII; hemophilia;

heparin therapy; liver disease

If the aPTT value is prolonged (longer than 100 seconds or per

agency policy) in a client receiving IV heparin therapy or in any client at

risk for thrombocytopenia, initiate bleeding precautions.

E. Prothrombin time (PT) and international normalized ratio (INR)

1. Prothrombin is a vitamin K–dependent glycoprotein

produced by the liver that is necessary for fibrin clot

formation.

2. Each laboratory establishes a normal or control value

based on the method used to perform the PT test.

3. The PT measures the amount of time it takes in

seconds for clot formation and is used to monitor

response to warfarin sodium therapy or to screen for

dysfunction of the extrinsic clotting system resulting

from liver disease, vitamin K deficiency, or

disseminated intravascular coagulation.

4. A PT value within 2 seconds (plus or minus) of the

control is considered normal.

5. The INR is a frequently used test to measure the

effects of some anticoagulants.

6. The INR standardizes the PT ratio and is calculated in

the laboratory setting by raising the observed PT ratio

to the power of the international sensitivity index

specific to the thromboplastin reagent used.

7. If a PT is prescribed, baseline specimen should be

drawn before anticoagulation therapy is started; note

the time of collection on the laboratory form.

8. Provide direct pressure to the venipuncture site for 3

to 5 minutes.

9. Concurrent warfarin therapy with heparin therapy can

lengthen the PT for up to 5 hours after dosing.

10. Diets high in green leafy vegetables can

increase the absorption of vitamin K, which shortens

the PT.

11. Orally administered anticoagulation therapy

usually maintains the PT at 1.5 to 2 times the

laboratory control value.

12. Normal reference intervals

a. PT: 11 to 12.5 seconds (conventional

and SI units)

b. INR: 0.81 to 1.20 (conventional and SI

units)

13. For both the PT and INR, elevated values occur in the

following: deficiency of one or more of the following:

factor I, II, V, VII, or X; liver disease; vitamin K

deficiency; warfarin therapy

If the PT value is longer than 25 seconds and the INR is

greater than 3.0 in a client receiving standard warfarin therapy (or per

agency policy), initiate bleeding precautions.

Thiazide diuretics (Box 53-7)

1. Description

a. Thiazide diuretics increase sodium and

water excretion by inhibiting sodium

reabsorption in the distal tubule of the

kidney.

b. Used for hypertension and peripheral

edema

c. Not effective for immediate diuresis

d. Used in clients with normal renal

function (contraindicated in clients

with renal failure)

e. Thiazide diuretics should be used with

caution in the client taking lithium,

because lithium toxicity can occur, and

in the client taking digoxin,

corticosteroids, or hypoglycemic

medications.

2. Side and adverse effects

a. Hypercalcemia, hyperglycemia,

hyperuricemia

b. Hypokalemia, hyponatremia

c. Hypovolemia

d. Hypotension

e. Rashes

f. Photosensitivity

g. Dehydration

3. Interventions

a. Monitor vital signs.

b. Monitor weight.

c. Monitor urine output.

d. Monitor electrolytes, glucose, calcium,

blood urea nitrogen (BUN), creatinine,

and uric acid levels.

e. Check peripheral extremities for edema.

f. Monitor for signs of digoxin or lithium

toxicity if the client is taking these

medications.

g. Instruct the client to take the

medication in the morning to avoid

nocturia and sleep interruption.

h. Instruct the client in how to record the

BP.

i. Instruct the client to eat foods high in

potassium.

j. Instruct the client in how to take

potassium supplements if prescribed.

k. Instruct the client to take medication

with food to avoid gastrointestinal

upset.

l. Instruct the client to change positions

slowly to prevent orthostatic

hypotension.

m. Instruct the client to use sunscreen

when in direct sunlight because of

increased photosensitivity.

n. Instruct the client with diabetes

mellitus to have the blood glucose

level checked periodically.

c. Hypovolemia

d. Hypotension

e. Rashes

f. Photosensitivity

g. Dehydration

3. Interventions

a. Monitor vital signs.

b. Monitor weight.

c. Monitor urine output.

d. Monitor electrolytes, glucose, calcium,

blood urea nitrogen (BUN), creatinine,

and uric acid levels.

e. Check peripheral extremities for edema.

f. Monitor for signs of digoxin or lithium

toxicity if the client is taking these

medications.

g. Instruct the client to take the

medication in the morning to avoid

nocturia and sleep interruption.

h. Instruct the client in how to record the

BP.

i. Instruct the client to eat foods high in

potassium.

j. Instruct the client in how to take

potassium supplements if prescribed.

k. Instruct the client to take medication

with food to avoid gastrointestinal

upset.

l. Instruct the client to change positions

slowly to prevent orthostatic

hypotension.

m. Instruct the client to use sunscreen

when in direct sunlight because of

increased photosensitivity.

n. Instruct the client with diabetes

mellitus to have the blood glucose

level checked periodically. Typing Service – Picture Document to Word Document

 

 

Cardiac Arrhythmias:

 Normal sinus rhythm- Peaks of p waves are evenly spaced

 V-fib- Chaotic squiggly line. No pattern

 V-tach- Sharp peak & jags. There’s a pattern

 Asystole- Flat line

 QRS depolarization- Answer will always be ventricular

 P wave- Answer will always be atrial

 Lack of a P wave- Answer will always be ventricular

 A lack of QRS- Asystole

 A-flutter- Saw tooth

 Chaotic is always the word used to describe fibrillation

 Bizarre is always the word used for tachycardia

Low Priority:

 Premature ventricular contraction (PVC)

 A bunch of PVC’s is like a short run of V-Tach

Moderate Priority:

 If more than 6 PVC’s in a minute or row and/or if PVC falls on the T wave of the previous beat. They never are high priority!

Potentially Life Threatening:

 V-Tach- Pt has a pulse

Lethal Priority: Kills you in 8 mins or less

 Asystole- No pulse

 V-fib- No pulse

Treatment:

Supra Ventricular (Atrial) → ABCD’s

Adenocard (Adenosine):

 Push in less then 8 secs

 Don’t worry about Asystole

 When it comes to IV push, when you don’t know go slow

Beta blockers (ending in “lol”)

 Just like CCB’s, same treatment, same side effects

Calcium channel blockers

 Better for asthmatics

Digoxin/Digitalis (Lanoxin)

V-fib → D-fib

Asystole → Epinephrine & Atropine (In that order if Epi doesn’t work)

PVC’s & V-Tach → Use Amiodarone for Ventricular. Typing Service – Picture Document to Word Document

 

 

 

 

 

 

. Typing Service – Picture Document to Word Document

 

 

Various interventions have been utilized for prophylaxis of venous thromboembolism. These include mechanical devices such as graduated compression stockings (GCS), intermittent pneumatic compression (IPC) devices, and pharmacologic agents such as unfractionated heparin, low-molecular-weight heparin. Anticoagulants, including injectables such as heparin or low molecular weight heparin, or tablets such as apixaban, dabigatran, rivaroxaban, edoxaban and warfarin (also called direct-acting oral anticoagulants or DOACs). These medications are used for a number of months.

 

U world Neurological all typed questions

aspiration pneumonia.

The home health nurse teaches an elderly client with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which statement indicates that the client needs further teaching?

· 1″| have to remember to raise my chin slightly upward when | swallow.” (56%)

 

 

Dysphagia increases the risk for aspiration of oropharyngeal secretions, gastric content, food, and/or fluid into the lungs. Aspiration of foreign material into the lungs increases the risk for developing aspiration pneumonia. Interventions to help decrease aspiration and resulting aspiration pneumonia in susceptible clients (eg, elderly, neurologic dysfunction, decreased cough or gag reflexes, decreased immunity, chronic disease), include the following: Typing Service – Picture Document to Word Document

· Swallowing 2 times before taking another bite of food. This clears food from the pharynx.

· Thickening liquids to assist swallowing

· Avoiding over-the-counter cold medications. Antihistamine cold preparation medications also have some anticholinergic properties, such as causing drowsiness, decreasing saliva (xerostomia) production, and making the mouth dry. Saliva is a lubricant, and it helps bind food together to facilitate swallowing.

· Sitting upright for at least 30-40 minutes after meals. This uses gravity to move food or fluid through the alimentary tract, decreases gastroesophageal reflux, and helps decrease risk for aspiration.

· Brushing teeth and using antiseptic mouthwash before and after meals. This reduces the bacterial count before eating because bacteria as well as food can be aspirated. After-meal use removes particles of food that can be aspirated later.

· Smoking cessation. Smoking decreases mucociliary clearance and increases bacterial count in the mouth.

 

(Option 1) Positioning the chin slightly downward toward the neck (chin-tuck) when swallowing can be effective in some clients with

dysphagia due to its facilitating closure of the epiglottis to help prevent tracheal aspiration.

Educational objective:

Teaching clients who are susceptible to aspiration about swallowing techniques, positioning, avoidance of over-the-counter cold

preparation medications (cause drowsiness and dry mouth), oral care, and smoking cessation can decrease the risk for aspiration

pneumonia

The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. What nursing actions help prevent this potential

complication during hospitalization? Select all that apply.

· 1.Add a thickening agent to the fluids

· 2. Avoid administering sedating medications before meals

· 3. Place the client in an upright position during meals

· 5. Teach the client to flex the neck while swallowing

Aspiration pneumonia develops when aspirated material (eg, food, emesis, gastric reflux) causes an inflammatory response and

provides a medium for bacterial growth. At-risk conditions include cognitive changes (eg, dementia, head injury, stroke, sedation),

difficulty swallowing, compromised gag reflex, and tube feeding.

Aspiration-prevention measures include:

· Thicken liquids (eg, to nectar or honey consistency) for clients with dysphagia; thin liquids are more difficult to control whenswallowing (Option 1).

· Ensure that the client is fully awake before eating. The nurse should time the administration of sedating medications (eg, opioids, benzodiazepines) to avoid sedation during meals (Option 2).

· Elevate the head of the bed to 90 degrees during and for 30 minutes after meals, and never place the head of the bed lower than 30 degrees (Option 3).

· Encourage clients to facilitate swallowing by flexing the neck (chin to chest) (Option 5).

· Administer prescribed antiemetics (eg, ondansetron) as needed to prevent vomiting.

· Monitor for coughing, gagging, and pocketing food. Typing Service – Picture Document to Word Document

 

(Option 4) Performing strict handwashing and limiting sick visitors are important infection-control measures; however, they do not

prevent noninfectious aspiration pneumonia.

Educational objective:

Measures for preventing aspiration pneumonia include administering medications to prevent vomiting, avoiding mealtime sedation,

maintaining head-of-bed elevation at 30 degrees or more (90 degrees during and 30 minutes after meals), and encouraging neck

flexion while swallowing. Clients with dysphagia should receive thickened liquids and be monitored for coughing, gagging, and

pocketing food.

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the

nurse make to evaluate if a complication from the mannitol is occurring?

· 1. Auscultate breath sounds to assess for crackles (49%)

 

 

Mannitol (Osmitrol) is an osmotic diuretic used to treat cerebral edema (increased intracranial pressure) and acute glaucoma. When administered, mannitol causes an increase in plasma oncotic pressure (similar to excess glucose) that draws free water from the extravascular space into the intravascular space, creating a volume expansion. This fluid, along with the drug, is excreted through the kidneys, thereby reducing cerebral edema and intracranial pressure. However, if a higher dose of mannitol is given or it accumulates (as in kidney disease), fluid overload that may cause life-threatening pulmonary edema results. An early sensitive indicator of fluid overload is new onset of crackles auscultated in the lungs. To prevent these complications, clients require frequent monitoring of serum osmolarity, input and output, serum electrolytes, and kidney function.

(Option 2) Urine output would be expected to increase from the diuretic effect of mannitol. This is not a complication.

(Option 3) Glasgow Coma Scale scores range from 3-15. Improved mental status (orientation, alertness) is a desired effect of

treatment.

(Option 4) The presence of crackles is a more sensitive sign of fluid overload than pedal edema. Furthermore, in a bedridden client, the assessment should take place at a dependent part of the body, usually the sacral area.

Educational objective:

Mannitol is an osmotic diuretic used to treat cerebral edema and acute glaucoma. Normal kidney function and adequate urine output are crucial while administering this medication as mannitol accumulation can result in significant volume expansion, dilutional hyponatremia, and pulmonary edema.

Aclient is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, “That’s weird, didn’t even feel nauseated.” Which action by the nurse is the most appropriate?

· 1. Document the amount of emesis (6%)

· 3. Notify the health care provider (HCP) (75%)

 

Unexpected and projectile vomiting without nausea can be a sign of increased ICP, especially in the client with a history of

increased ICP. The unexpected vomiting is related to pressure changes in the cranium. The vomiting can be associated with

headache and gets worse with lowered head position. The most appropriate action is to obtain a full set of vital signs and contact the HCP immediately.

(Option 1) Documentation is important, but it is not the priority action.

(Option 2) The head of the bed should be raised, not lowered, for clients with suspected increased ICP. Raising the head of the bed to 30 degrees helps to drain the cerebrospinal fluid via the valve system without lowering the cerebral blood pressure.

(Option 4) The vomiting is caused not by nausea but by pressure changes in the cranium. Anti-nausea medications are often not effective. Decreasing intracranial pressure will help the vomiting.

Educational objective:

Notify the HCP of signs/symptoms of increased ICP, including unexpected vomiting. The vomiting is often projectile, associated with headache, and gets worse with lowering the head position.

The nurse is assessing a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings does the

nurse expect? Select all that apply.

· 2. Difficulty breathing

· 3. Difficulty swallowing

· 4. Muscle weakness

 

Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease) is a debilitating neurodegenerative disease with no cure. ALS causes progressive degeneration of motor neurons in the brain and spinal cord. Physical symptoms include fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure (Options 2, 3, and 4). Most clients survive only 3-5 years after the diagnosis as there is no cure. Treatment focuses on symptom management. Interventions include:

 

· Respiratory support with noninvasive positive pressure (eg, bilevel positive airway pressure [BiPAP]) or invasive mechanical ventilation (eg, via tracheostomy)

· Feeding tube for enteral nutrition

· Medications to decrease symptoms (eg, spasms, uncontrolled secretions, dyspnea)

· Mobility assistive devices (eg, walker, wheelchair)

· Communication assistive devices (eg, alphabet boards, specialized computers)

(Option 1) Constipation due to decreased mobility is more common in ALS. Diarrhea is not seen.

(Option 5) Resting tremor is characteristic of parkinsonism,

Educational objective:

Amyotrophic lateral sclerosis causes motor neuron degeneration that leads to progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure. There is no cure. Treatment focuses on symptom management.

The daughter of an 80-year-old client recently diagnosed with Alzheimer disease (AD) says to the nurse, “| guess | can anticipate

getting this disease myself at some point.” What is an appropriate response by the nurse?

· 1. “Engaging in regular exercise decreases the risk of AD.” (52%)

 

 

The development of Alzheimer disease (AD) is related to a combination of genetic, lifestyle, and environmental factors. Clients with

AD are usually diagnosed at age 265. Early-onset AD is a rare form of the disease that develops before age 60 and is strongly related

to genetics. Children of clients with early-onset AD have a 50% chance of developing the disease.

For late-onset AD, the strongest known risk factor is advancing age. Having a first-degree relative (eg, parent, sibling) with late-

onset AD also increases the risk of developing AD (Option 2). Trauma to the brain has been associated with the development of AD

in the future. Brain trauma may be prevented by wearing seat belts and sports helmets and taking measures to prevent falls.

 

Research suggests that healthy lifestyle choices (eg, smoking cessation, avoiding excessive alcohol intake, exercising regularly,

participating in mentally challenging activities) reduce the risk for developing AD (Options 1 and 3).

 

(Option 4) Research has failed to confirm that exposure to aluminum products (eg, cans, cookware, antiperspirant deodorant) is

related to the development of AD.

Educational objective:

Research suggests that healthy lifestyle choices (eg, smoking cessation, avoiding excessive alcohol intake, exercising regularly,

participating in mentally challenging activities) reduce the risk for developing Alzheimer disease.

The emergency department nurse is assessing a client brought in after a car accident in which the client’s head hit the steering column. Which assessment findings would indicate that the triage nurse should apply spinal immobilization? Select all that apply.

· 1. Breath smells of alcohol

· 2. Client disoriented to place

· 5. Point tenderness over spine

 

Spinal immobilization is not a benign procedure. An acronym to help determine the need for spinal immobilization is NSAIDs:

N – Neurological examination. Focal deficits include numbness and decreased strength.

S – Significant traumatic mechanism of injury

A-Alertness. The client may be disoriented or have an altered level of consciousness (Option 2).

| – Intoxication. The client could have impaired decision-making ability or lack awareness of pain (Option 1).

D – Distracting injury. Another significant injury could distract the client from spinal pain.

S- Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline tenderness) may be present

(Option 5).

(Option 3) The sensation of burning eyes could be related to many issues and does not necessarily have a direct correlation to spinal

trauma.

(Option 4) There is no direct correlation of multiple sclerosis (autoimmune progressive nerve demyelinization) with the need for spinal immobilization.

Educational objective:

Indications for spinal immobilization include abnormal neurological findings, significant mechanism of injury, change in orientation or level of consciousness, intoxication, distracting injury, and point tenderness over the spine.

The nurse is caring for a client who had a stroke two weeks ago and has moderate receptive aphasia. Which interventions should the

nurse include in the plan of care to help the client follow simple commands regarding activities of daily living (ADL)? Select all that

apply.

· 1. Ask simple questions that require “yes” or “no” answers

· 3. Remain calm and allow the client time to understand each instruction

· 4. Show the client pictures of ADL (eg, shower, toilet, and toothbrush) or use gestures

5. Speak slowly but loudly while looking directly at the client

Receptive aphasia refers to impairment or loss of language comprehension (ie, speech, reading) that is caused by a neurological

condition (eg, stroke, traumatic brain injury). The terms “aphasia” and “dysphasia” can be used interchangeably as both refer to

impaired communication; however, “aphasia” is more commonly used.

When assisting a client with receptive aphasia to complete activities of daily living, the nurse should avoid completing tasks for the

client and should instead encourage independence using appropriate communication techniques. Appropriate interventions to aid

communication include:

· Ask short, simple, “yes” or “no” questions (Option 1).

· Use gestures or pictures (eg, communication board) to demonstrate activities (Option 4).

· Remain patient and calm, allowing the client time to understand each instruction (Option 3).

(Option 2) Clients with aphasia often become frustrated due to inability to communicate effectively. Frustration does not result from

the nurse’s care, so reassigning the client to a different care provider is not an effective solution.

(Option 5) Eye contact is important in all communication, but raising the voice will not help. Speaking loudly will not improve

comprehension and may increase anxiety and confusion.