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A 15-year-old boy is in the ICU and preparing for an appendectomy. He is clearly anxious and fidgets with his IV constantly. He complains that he doesnt want to be there and he is sick of everyone telling him what to do. What would be the best way for the nurse to address this patients anxiety?
- A. Use physical restraints to keep him from pulling out his IV.
- B. Offer him the remote to the television.
- C. Lower the head of his bed so that he can rest more easily.
- D. Explain to the patient in detail what the appendectomy will consist of.
Correct Answer: B
Rationale: The correct answer is B: Offer him the remote to the television. This is the best way to address the patient's anxiety because it provides a distraction and a sense of control, which can help alleviate anxiety. By offering the patient the remote to the television, the nurse is giving him a choice and a way to focus his attention away from his anxiety. This can help him feel more comfortable and empowered in the situation.
Choice A is incorrect because using physical restraints can increase the patient's anxiety and sense of helplessness. Choice C, lowering the head of his bed, may provide physical comfort but does not directly address his anxiety. Choice D, explaining the procedure in detail, may further increase his anxiety as it focuses on the surgery rather than addressing his current emotional state.
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The most common cause of acute kidney injury in critically ill patients is
- A. sepsis.
- B. fluid overload.
- C. medications.
- D. hemodynamic instability.
Correct Answer: A
Rationale: The correct answer is A: sepsis. Sepsis is the most common cause of acute kidney injury in critically ill patients due to the systemic inflammatory response causing renal hypoperfusion. Sepsis leads to a decrease in renal blood flow, resulting in acute kidney injury. Fluid overload (B) can contribute to renal dysfunction but is not the primary cause in critically ill patients. Medications (C) can cause kidney injury, but sepsis is more prevalent. Hemodynamic instability (D) is a consequence of sepsis and can lead to acute kidney injury, making it an indirect cause.
The nurse is concerned about the risk of alcohol withdraw al syndrome in a 45-year-old postoperative patient. Which statement indicates an unders tanding of management of this patient?
- A. “Alcohol withdrawal is common; we see it all of the tiambierb .icno mth/tees tt rauma unit.”
- B. “There is no way to assess for alcohol withdrawal.”
- C. “This patient will require less pain medication.”
- D. “We have initiated the alcohol withdrawal protocol.”
Correct Answer: D
Rationale: The correct answer is D because initiating the alcohol withdrawal protocol shows an understanding of managing a patient at risk for alcohol withdrawal syndrome. This protocol involves carefully monitoring the patient's symptoms, providing appropriate medications, and ensuring a safe environment. Option A is incorrect as it downplays the seriousness of alcohol withdrawal. Option B is incorrect as there are assessment tools available for identifying alcohol withdrawal. Option C is incorrect as pain management should be tailored to the individual's needs, not necessarily lessened due to alcohol withdrawal risk.
A nurse decides to seek certification in critical care nursing. What is the most important benefit for the individual nurse in becoming certified in a specialty?
- A. It will result in a salary increase.
- B. It is required to work in critical care.
- C. It demonstrates the nurses personal expertise.
- D. It is mandated by employers.
Correct Answer: C
Rationale: The correct answer is C because obtaining certification in critical care nursing demonstrates the nurse's personal expertise in the specialty. Certification confirms the nurse's advanced knowledge and skills, enhancing professional credibility and potential for career advancement. This choice focuses on the individual nurse's competency and dedication to the specialty.
Incorrect choices:
A: Salary increase is not the primary benefit of certification, although it may be a potential outcome.
B: Certification is often preferred but not always required to work in critical care.
D: Employers may encourage certification, but it is not always mandated.
A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam 1 to 2 mg IV as needed (prn). The patient has received no lorazepam during this course of illness. What is the most appropriate nursing intearbvirbe.ncotmio/tnes tt o control agitation?
- A. Administer fentanyl (Duragesic) 25 mg IV bolus.
- B. Administer midazolam 2 mg IV now.
- C. Increase the rate of the morphine infusion by 50%.
- D. Request an order for a paralytic agent.
Correct Answer: B
Rationale: Step-by-step rationale for why choice B is correct:
1. Midazolam is a benzodiazepine used for sedation and anxiolysis.
2. It acts quickly and has a short duration of action, suitable for acute agitation.
3. Lorazepam (also a benzodiazepine) is in the same drug class, ensuring compatibility.
4. Lorazepam is specifically ordered for this patient, indicating its appropriateness.
5. Administering midazolam addresses the patient's agitation efficiently and safely.
Summary of why other choices are incorrect:
A: Fentanyl is an opioid analgesic, not ideal for managing agitation.
C: Increasing morphine infusion can exacerbate sedation or respiratory depression.
D: Paralytic agents are used for neuromuscular blockade, not agitation control.
The critical care unit environment is very stressful for patients, families, and staff. What nursing action is directed at reducing environmental stress?
- A. Constant evaluation of patient status
- B. Limiting visits to immediate family
- C. Bathing all patients during hours of sleep
- D. Maintaining quiet during hours of sleep
Correct Answer: D
Rationale: The correct answer is D: Maintaining quiet during hours of sleep. This action is essential in reducing environmental stress in the critical care unit as it promotes a restful environment for patients and allows for better sleep quality. Noise can disrupt sleep patterns and increase stress levels. Constant evaluation of patient status (A) is important but does not directly address environmental stress. Limiting visits to immediate family (B) can be beneficial in some cases but may not always reduce environmental stress. Bathing all patients during hours of sleep (C) may actually increase stress as it can be disruptive and uncomfortable for patients. Overall, maintaining a quiet environment during sleep hours is the most effective nursing action to reduce environmental stress in the critical care unit.