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 C

Explanation

A. Partially compensated Metabolic Alkalosis: This is incorrect because the pH is within normal limits (7.35-7.45), and the elevated PaCO2 and bicarbonate suggest a respiratory issue rather than a metabolic one.

B. Fully compensated Metabolic Acidosis: This is incorrect because the primary disturbance is respiratory, not metabolic. A compensated metabolic acidosis would typically show a low PaCO2 as compensation.

C. Fully compensated Respiratory Acidosis: Correct. The pH is within the normal range, indicating full compensation. The elevated PaCO2 and bicarbonate reflect a chronic respiratory acidosis that has been compensated by the kidneys.

D. Partially compensated Respiratory Alkalosis: This is incorrect because in respiratory alkalosis, the PaCO2 would be low, not high.

A. Grey-Turner Sign B. Steatorrhea C. Asterixis D. Cullen's Sign

Correct Answer is D

Explanation

A. Grey-Turner Sign: Grey-Turner Sign refers to bruising along the flanks, often associated with retroperitoneal hemorrhage or acute pancreatitis.

B. Steatorrhea: Steatorrhea refers to fatty stools that are pale, bulky, and foul-smelling, indicating malabsorption, not a physical exam finding on the skin.

C. Asterixis: Asterixis, also known as "liver flap," is a tremor of the hand when the wrist is extended, seen in hepatic encephalopathy, not a skin finding.

D. Cullen's Sign: Cullen's Sign is bruising around the umbilicus, indicating intra-abdominal bleeding, often seen in conditions such as acute pancreatitis or ruptured ectopic pregnancy.

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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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