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In the critically ill patient, an incomplete assessment and/or management of pain or anxiety may be hampered by which of the following? (Select all that apply.)
- A. Administration of neuromuscular blocking agents
- B. Delirium
- C. Effective nurse communication and assessment skills
- D. Nonverbal patients
Correct Answer: A
Rationale: Step-by-step rationale:
1. Administration of neuromuscular blocking agents can hinder pain or anxiety assessment as it paralyzes the patient, preventing them from communicating discomfort.
2. Delirium may affect the patient's ability to express pain or anxiety, but it does not directly impede assessment and management.
3. Effective nurse communication and assessment skills facilitate, rather than hamper, pain or anxiety assessment.
4. Nonverbal patients can still communicate pain or anxiety through nonverbal cues, so they do not necessarily hinder assessment.
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A Muslim woman is admitted to the ICU after suffering severe burns over most of her body. Which of the following would be the most appropriate measure for the nurse, a woman, to take in respect for the cultural practices of this patient?
- A. Insist that only a female doctor be assigned to this patient.
- B. Ensure that no pork products are included in the patients diet.
- C. Ensure that direct eye contact is not made with the patients husband.
- D. Ask the patients husband what religious and cultural preferences should be considered in the patients care.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates respect for the patient's autonomy and individual preferences. By asking the patient's husband about religious and cultural preferences, the nurse acknowledges the importance of involving the family in decision-making and shows sensitivity to the patient's beliefs. This approach promotes cultural competence and patient-centered care.
Choice A is incorrect because insisting on a female doctor may not align with the patient's preferences and may limit the available medical staff. Choice B is also incorrect as dietary restrictions are not necessarily the most pressing issue in this scenario. Choice C is incorrect as it assumes a cultural practice without verifying the patient's specific preferences and may not be necessary or appropriate in this context.
The nurse is managing a donor patient six hours prior to th e scheduled harvesting of the patient’s organs. Which assessment finding requires imme diate action by the nurse?
- A. Morning serum blood glucose of 128 mg/dL
- B. pH 7.30; PaCO 38 mm Hg; HCO 16 mEq/L 2 3
- C. Pulmonary artery temperature of 97.8° F
- D. Central venous pressure of 8 mm Hg
Correct Answer: B
Rationale: The correct answer is B. The patient's pH of 7.30 indicates acidosis, PaCO2 of 38 mm Hg is low, and HCO3 of 16 mEq/L is also low, suggesting metabolic acidosis. This finding requires immediate action as untreated acidosis can lead to serious complications.
Choice A (morning serum blood glucose of 128 mg/dL) is within normal range and does not require immediate action.
Choice C (pulmonary artery temperature of 97.8°F) is a normal temperature and does not require immediate action.
Choice D (central venous pressure of 8 mm Hg) is within normal range and does not require immediate action.
Which statement regarding ethical concepts is true?
- A. A living will is the same as a healthcare proxy.
- B. A signed donor card ensures that organ donation will o ccur in the event of brain death.
- C. A surrogate is a competent adult designated by a perso n to make healthcare decisions in the event the person is incapacitated.
- D. A persistent vegetative state is the same as brain deatha ibnir bm.cooms/tt esstt ates.
Correct Answer: C
Rationale: Rationale: Choice C is correct because a surrogate is indeed a competent adult designated to make healthcare decisions for an incapacitated person. This individual is typically chosen by the person themselves through a legal document like a healthcare proxy. This ensures that someone trusted can make important decisions when the person is unable to do so. Choices A, B, and D are incorrect because a living will and healthcare proxy serve different purposes, a signed donor card does not guarantee organ donation in the event of brain death (medical criteria are also required), and a persistent vegetative state is different from brain death (brain death implies irreversible cessation of brain function while a vegetative state involves some level of brain function).
The nurse cares for an adolescent patient who is dying. The patient’s parents are interested in organ donation and ask the nurse how the decision about brain death is made. Which response by the nurse is most appropriate?
- A. Brain death occurs if a person is flaccid and unresponsive.
- B. If CPR is ineffective in restoring a heartbeat, the brain cannot function.
- C. Brain death has occurred if there is no breathing and certain reflexes are absent.
- D. If respiratory efforts cease and no apical pulse is audible, brain death is present.
Correct Answer: C
Rationale: The correct answer is C: Brain death has occurred if there is no breathing and certain reflexes are absent. Brain death is defined as the irreversible cessation of all functions of the entire brain, including the brainstem. The absence of breathing and certain reflexes, such as no response to painful stimuli or no pupillary response to light, are key indicators of brain death. This definition is crucial for determining eligibility for organ donation.
Incorrect choices:
A: Brain death occurs if a person is flaccid and unresponsive. Flaccidity and unresponsiveness are not specific criteria for diagnosing brain death.
B: If CPR is ineffective in restoring a heartbeat, the brain cannot function. The absence of a heartbeat alone does not indicate brain death.
D: If respiratory efforts cease and no apical pulse is audible, brain death is present. Respiratory cessation and the absence of pulse are not definitive signs of brain death.
Renin plays a role in blood pressure regulation by
- A. activating the renin-angiotensin-aldosterone cascade.
- B. suppressing angiotensin production.
- C. decreasing sodium reabsorption.
- D. inhibiting aldosterone release.
Correct Answer: A
Rationale: The correct answer is A because renin activates the renin-angiotensin-aldosterone cascade, which ultimately leads to vasoconstriction, increased blood pressure, and aldosterone release to increase sodium and water reabsorption. Renin does not suppress angiotensin production (B), decrease sodium reabsorption (C), or inhibit aldosterone release (D), as these actions would counteract its role in blood pressure regulation.