Author Question: While the nurse is assessing the patient's respirations, it is important for the patient to a. Be ... (Read 190 times)

cartlidgeashley · **on:** Jul 22, 2018

While the nurse is assessing the patient's respirations, it is important for the patient to

a. Be aware of the procedure being done.
b. Not know that respirations are being assessed.
c. Understand that respirations are estimated to save time.
d. Not be touched until the entire process is finished.

Question 2

Which intervention is most appropriate for the nursing diagnostic statement, Impaired verbal communication related to loss of facial motor control and decreased sensation?

a. Obtain an interpreter for the patient as soon as possible.
b. Assist the patient in performing swallowing exercises each shift.
c. Ask the family to provide a sitter to remain with the patient at all times.
d. Provide the patient with a writing board each shift.

lcapri7 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
Do not let a patient know that respirations are being assessed. A patient who is aware of the assessment can alter the rate and depth of breathing. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations. Accurate measurement requires observation and palpation of chest wall movement.

Answer to Question 2

D
The cause of the patient's problem will help guide the nurse to the proper nursing intervention. If the patient has a problem with verbal communication, then the nurse should choose an intervention that will address the problem. Providing the patient with a writing board will allow the patient to communicate by writing because the patient is unable to communicate verbally at this time. Obtaining an interpreter might be an appropriate intervention if the patient spoke a foreign language. Assisting with swallowing exercises will help the patient with swallowing, which is a different nursing diagnosis from Impaired verbal communication. Asking the family to provide a sitter at all times is many times unrealistic and does not promote the patient's independence, as does providing a writing board.