A female client with aphasia is trying to verbalize feelings to the nurse and states, "I want...," but does not finish the statement. How should the nurse respond to this unfinished statement?

Offer the client to move to a quiet room first.

Allow the client time to complete her sentence.

Pull up a chair and sit quietly with the client.

Provide a list of phrases to express her-self properly.

Answer and Explanation

The Correct Answer is B

A. Offer the client to move to a quiet room first: Changing the environment may reduce distractions, but it does not directly support the client’s immediate attempt to communicate. The priority is to respond to the client’s active effort to speak in the moment.

B. Allow the client time to complete her sentence: Allowing extra time promotes autonomy, reduces frustration, and respects the communication process for clients with aphasia. It gives the client space to formulate thoughts without pressure or interruption, which supports language recovery and expression.

C. Pull up a chair and sit quietly with the client: Sitting quietly can offer emotional support, but it may be perceived as passive when the client is actively trying to communicate. The nurse should take a facilitative role by giving the client time to speak, rather than only offering silent presence.

D. Provide a list of phrases to express herself properly: Providing phrases may overwhelm or confuse the client, especially during spontaneous attempts to speak. Aphasia affects word retrieval, and prompting with choices may interrupt the client's cognitive effort.

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Correct Answer is D

Explanation

A. Only when a client presents with an unexplained injury: Waiting for physical signs misses many victims, especially those experiencing emotional or sexual abuse without visible injuries.

B. As soon as the clinician suspects a problem: While suspicion should prompt further evaluation, relying on suspicion alone delays early detection and intervention for many at-risk individuals.

C. Once the clinician confirms a history of abuse: Screening is a preventive tool used to detect abuse early; waiting for confirmation defeats the purpose and allows ongoing harm.

D. As a routine part of each health care encounter: Routine screening normalizes the process, reduces stigma, and increases the likelihood of identifying and helping those experiencing IPV.

A. Monitor ETT markings between 22 and 26 cm at teeth line. B. Check for capillary refill of 3 seconds or less. C. Auscultate for presence of bilateral breath sounds. D. Obtain a portable chest x-ray to verify ETT location. E. Assess for symmetrical chest movement.

Correct Answer is ["C","D","E"]

Explanation

A. Monitor ETT markings between 22 and 26 cm at teeth line: While the placement marking on the ETT can be useful for initial placement, it is not the most reliable way to confirm correct positioning. ETT placement should always be verified by clinical assessment rather than relying solely on measurements.

B. Check for capillary refill of 3 seconds or less: Capillary refill is a general indicator of peripheral circulation and does not directly assess whether the ETT is properly placed in the trachea. It is not useful for confirming ETT placement.

C. Auscultate for presence of bilateral breath sounds: This is a key assessment to confirm that the ETT is properly placed. Bilateral breath sounds indicate that air is entering both lungs, suggesting that the tube is correctly positioned in the trachea and not in the esophagus.

D. Obtain a portable chest x-ray to verify ETT location: A chest x-ray is the gold standard for confirming the correct placement of the ETT. It provides an accurate visual confirmation of the tube’s position relative to the carina and the lungs.

E. Assess for symmetrical chest movement: Symmetrical chest movement is another important assessment to confirm proper ETT placement. If the ETT is correctly placed in the trachea, both sides of the chest will rise and fall equally with each breath, indicating effective ventilation.

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A female client with aphasia is trying to verbalize feelings to the nurse and states, "I want...," but does not finish the statement. How should the nurse respond to this unfinished statement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When should intimate partner violence (IPV) screening occur?

Correct Answer is D

Explanation

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

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