A client with a tracheostomy attempts to speak but is unable.
What should the nurse do?
Tell the client to keep trying.
Avoid communication until speech returns.
Provide alternative communication methods, such as writing or gestures.
Ask the family to interpret the client's needs.
The Correct Answer is C
Choice A rationale
Encouraging the client to keep trying to speak while the tracheostomy tube is in place and the cuff is inflated can lead to extreme frustration and physical exhaustion. Because air is diverted through the tube rather than passing over the vocal cords, vocalization is physiologically impossible or severely muffled for many. Forcing the effort without a speaking valve can cause unnecessary stress and anxiety for a patient already dealing with a compromised airway.
Choice B rationale
Avoiding communication is detrimental to the patient's psychological well-being and safety. Clients with tracheostomies are often highly anxious due to their inability to vocalize needs or fears. Neglecting communication can lead to feelings of isolation, helplessness, and the potential for life-threatening needs to go unaddressed. A nurse must prioritize finding ways to maintain a connection to ensure the patient feels heard, safe, and involved in their own plan of care.
Choice C rationale
Providing alternative communication methods is the standard of care for patients with expressive barriers. Using tools like whiteboards, picture boards, or simple hand gestures allows the patient to convey urgent needs, such as pain or difficulty breathing, effectively. This intervention reduces patient anxiety and empowers them to participate in their care. It also ensures that the nursing staff can accurately assess the patient's condition despite the temporary loss of verbal speech capabilities.
Choice D rationale
While the family can provide emotional support, the nurse should not rely on them as the primary interpreters of clinical needs. The nurse is responsible for establishing a direct and reliable communication channel with the patient to ensure accurate assessment and safety. Relying on third parties can lead to misinterpretations of the patient's symptoms or desires. Direct communication tools ensure the patient's autonomy is respected and that the information gathered is medically reliable and timely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Written materials should never be the sole method of instruction because they do not allow for real-time clarification, demonstration, or assessment of the client's understanding. Effective patient education is multimodal, incorporating verbal discussion, visual aids, and return demonstrations. Relying only on printed text ignores diverse learning styles and may fail if the patient has visual impairments, low literacy levels, or cognitive deficits that prevent them from processing written information without supplemental guidance.
Choice B rationale
Providing materials in the client's preferred language is essential for ensuring health literacy and patient safety. Information presented in a language the client does not fully master leads to misunderstandings regarding medication dosages, warning signs, and follow-up care. Culturally and linguistically appropriate services are mandated in many healthcare settings to ensure that all patients have equal access to vital health information, which significantly improves compliance and outcomes by reducing communication barriers.
Choice C rationale
Teaching materials that attempt to cover every single aspect of care simultaneously can become overwhelming and counterproductive for the learner. Cognitive load theory suggests that presenting too much information at once hinders the retention of the most critical points. Education should be prioritized and staged, focusing on the most immediate and essential "need-to-know" information first. Overly dense documents are often ignored or misunderstood, whereas concise, focused materials better facilitate the learning process.
Choice D rationale
Using medical jargon in teaching materials is a significant barrier to effective communication. Materials should be written at a fifth to eighth-grade reading level to be accessible to the general population. Terms like "ambulate" should be replaced with "walk," and "prandial" with "mealtime.”. Using complex technical language can alienate the patient, cause confusion, and lead to medical errors if the patient is unable to translate the professional terminology into actionable daily tasks.
Correct Answer is B
Explanation
Choice A rationale
Clearing the hallway of equipment is an important safety measure during a fire to ensure that evacuation routes are unobstructed and that emergency personnel can move freely. However, this action does not correspond to the letter C in the RACE acronym. Equipment management is part of the general safety protocol but is not the primary focus of the specific mnemonic used for immediate fire response in most healthcare facility training programs.
Choice B rationale
In the RACE acronym, C stands for Confine the fire. This is achieved by closing doors and windows to prevent the spread of smoke and oxygen from fueling the flames. By confining the fire to a specific area, the staff can protect clients in other parts of the building and buy time for the fire department to arrive. This step is crucial for containing the hazard and is the standard meaning of the letter.
Choice C rationale
Calling the fire department is a vital step in fire safety, but in the RACE acronym, the letter A typically stands for Alarm or Activate the alarm. While notifying authorities is part of the overall response, the letter C is reserved for confinement. Following the sequence of Rescue, Alarm, Confine, and Extinguish ensures that all critical actions are taken in a logical order to maximize the safety of everyone in the healthcare facility.
Choice D rationale
While closing doors and windows is the physical action taken to fulfill the requirement of the acronym, the word represented by the letter C is Confine. The goal of closing these barriers is to limit the fire's movement. In many testing and training environments, the specific term Confine is used to describe this stage. Understanding the terminology helps ensure clear communication among staff members during an emergency situation when quick thinking is necessary.
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