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. Performing a 12-lead ECG: An ECG is the most definitive and immediate tool to determine if chest pain is cardiac in origin, as it can detect ischemic changes, arrhythmias, or other cardiac abnormalities.

B. Administering NTG to see if the pain goes away: While nitroglycerin (NTG) may relieve ischemic chest pain, it is not definitive for diagnosing the pain's origin and should not be the first step without further assessment.

C. Gathering a complete medical history: Although a medical history is important, it will not immediately determine if the pain is cardiac in origin.

D. Asking the patient if performing a Valsalva maneuver reduces the pain: The Valsalva maneuver is not a reliable method to differentiate cardiac from non-cardiac chest pain and could potentially worsen certain conditions.

A. "A complex measurement that should only be discussed with your health care provider." B. "A measurement that should always be 120/80 unless complications are present." C. "A measurement that takes into consideration the amount of blood that your heart is pumping and the size of the vessel diameter the heart must pump against.” D. "The amount of pressure exerted on your veins by the blood."

Correct Answer is C

Explanation

A. "A complex measurement that should only be discussed with your health care provider": This response is dismissive and does not provide the patient with valuable information or education.

B. "A measurement that should always be 120/80 unless complications are present": While 120/80 mmHg is a common target, blood pressure varies based on individual health and other factors.

C. "A measurement that takes into consideration the amount of blood that your heart is pumping and the size of the vessel diameter the heart must pump against": This response accurately explains that blood pressure is the force of blood against the walls of the arteries and is influenced by cardiac output and vascular resistance.

D. "The amount of pressure exerted on your veins by the blood": Blood pressure refers to the pressure within the arteries, not veins.

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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

What action would be most helpful to the nurse in determining whether the chest pain of a patient who has just entered the emergency department is cardiac in origin?

Correct Answer is A

Explanation

A patient asks the nurse, "What is blood pressure?" The nurse would most appropriately respond:

Correct Answer is C

Explanation

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