A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client?

Ask a family member to interpret what the client is trying to communicate.

Ask the physician to wean the client off the mechanical ventilator to allow the client to talk.

Ask the client to write, use a picture board, or spell words with an alphabet board.

Assure the client that everything will be all right and that he shouldn't become upset.

Answer and Explanation

The Correct Answer is C

A. Ask a family member to interpret what the client is trying to communicate: While family members can sometimes help, the nurse should directly facilitate communication with the client using appropriate tools.

B. Ask the physician to wean the client off the mechanical ventilator to allow the client to talk: Weaning off a ventilator should only be done based on medical stability, not solely for communication purposes.

C. Ask the client to write, use a picture board, or spell words with an alphabet board: These tools can help non-verbal clients on mechanical ventilation express themselves and reduce frustration.

D. Assure the client that everything will be all right and that he shouldn't become upset: This response is dismissive and does not address the client's need to communicate.

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Correct Answer is A

Explanation

A. ST segment elevation: ST segment elevation is a classic sign of myocardial injury, indicating that a portion of the heart muscle is not receiving enough oxygen and is actively injured.

B. Q wave: A Q wave typically appears later, representing a previous myocardial infarction (necrosis), not acute injury.

C. Inverted T wave: This indicates myocardial ischemia, which is a precursor to injury but not indicative of injury itself.

D. ST segment depression: This is typically associated with ischemia or subendocardial infarction, not full-thickness myocardial injury.

A. Assess the cause of the agitation. B. Reassure the client that he or she is safe. C. Restrain the client's hands. D. Sedate the client immediately.

Correct Answer is A

Explanation

A. Assess the cause of the agitation: This is the most appropriate action. Agitation in a mechanically ventilated patient can be due to multiple causes, such as pain, hypoxia, or discomfort. It is crucial to assess and identify the underlying cause to address it appropriately.

B. Reassure the client that he or she is safe: While reassurance is important, it may not address the root cause of the agitation, especially if it is related to a physical issue such as hypoxia or tube displacement.

C. Restrain the client's hands: Restraining should be a last resort after other interventions have failed. Restraints can cause further agitation and distress.

D. Sedate the client immediately: Sedating the client without assessing the cause of the agitation could mask serious issues and lead to inappropriate treatment.

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A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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