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A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
- A. Has the client experienced constipation recently?
- B. Did the client miss any doses of the medication?
- C. How long has the client been taking the medication?
- D. Does the client use any tobacco products?
Correct Answer: C
Rationale: The correct answer is C. Assessing how long the client has been taking clonidine is crucial as drowsiness is a common side effect that typically improves over time as the body adjusts to the medication. This information helps determine if the drowsiness is a temporary side effect or a more concerning issue.
Choice A (constipation) is not directly related to drowsiness as a side effect of clonidine. Choice B (missed doses) may contribute to drowsiness but is not the primary assessment priority. Choice D (tobacco use) is not directly related to clonidine-induced drowsiness.
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A patient in the ICU is recovering from open-heart surgery. The nurse enters his room and observes that his daughter is performing effleurage on his arms and talking in a low voice about an upcoming family vacation that is planned. The room is dimly lit, and she hears the constant beeping of his heart monitor. From the hall she hears the cries of a patient in pain. Which of the following are likely stressors for the patient? Select all that apply.
- A. His daughters conversation
- B. His daughters effleurage
- C. The beeping of the heart monitor
- D. The dim lighting of the room
Correct Answer: C
Rationale: The correct answer is C: The beeping of the heart monitor is a likely stressor for the patient recovering from open-heart surgery in the ICU. The constant beeping can cause anxiety and uncertainty about their health status. The daughter's conversation and effleurage are likely comforting and supportive for the patient, reducing stress. The dim lighting may create a calming environment, and the distant cries of a patient in pain may evoke empathy but may not directly stress the recovering patient. Therefore, the beeping of the heart monitor stands out as a stressor among the choices provided.
Family members have a need for information. Which intervention best assists in meeting this need?
- A. Handing family members a pamphlet that explains all of the critical care equipment
- B. Providing a daily update of the patient’s progress and f acilitating communication with the intensivist
- C. Telling them that you are not permitted to give them a status report but that they can be present at 4:00 PM for family rounds with the intensivist
- D. Writing down a list of all new medications and doses a nd giving the list to family members during visitation
Correct Answer: B
Rationale: The correct answer is B because providing a daily update of the patient's progress and facilitating communication with the intensivist directly addresses the family members' need for information in a timely and personalized manner. This intervention ensures that the family is kept informed about the patient's condition and treatment plan, fostering transparency and trust. It also allows for any questions or concerns to be addressed promptly, aiding in the family's understanding and involvement in the patient's care.
Now, let's summarize why the other choices are incorrect:
A: Handing out a pamphlet may provide information, but it lacks the personalized touch and real-time updates that are crucial for meeting the family's need for information.
C: Restricting information and only allowing family members to be present at specific times may create frustration and hinder communication, not effectively meeting their information needs.
D: Providing a list of medications is helpful, but it does not offer a comprehensive update on the patient's progress or facilitate direct communication with the medical team, which are
assessment, the patient is restless, heart rate has increased to 110 beats/min, respirat ions are 36 breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sin us tachycardia with 10 premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretio ns. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. In comambirubn.ciocma/tteinstg with the physician, which statement indicates the nurse understands what is likely occurring with the patient?
- A. “May we have an order for cardiac enzymes? This pati ent is exhibiting signs of a myocardial infarction.”
- B. “My assessment indicates potential fluid overload.”
- C. “The patient is having frequent PVCs that are comprom ising the cardiac output.”
- D. “The patient is having a hypertensive crisis; what medications would you like to order?”
Correct Answer: B
Rationale: The correct answer is B: “My assessment indicates potential fluid overload.” The patient is showing signs of fluid overload, such as increased heart rate, respiratory rate, elevated blood pressure, pulmonary artery pressures, frothy secretions, and crackles in lung fields. These symptoms suggest fluid is accumulating in the lungs, causing pulmonary congestion. This can lead to impaired gas exchange and respiratory distress. The nurse's recognition of these signs is crucial for prompt intervention to prevent further complications. Other choices are incorrect because there are no indications of a myocardial infarction, PVCs compromising cardiac output, or a hypertensive crisis based on the given information.
The nurse is caring for a patient who has an intra-aortic balloon pump (IABP) following a massive heart attack. When assessing the patient, the nurse notices blood backing up into the IABP catheter. In which order should the nurse take the following actions?
- A. Ensure that the IABP console has been turned off.
- B. Assess the patient's vital signs and orientation.
- C. Notify the healthcare provider of the IABP malfunction.
- D. Obtain supplies for insertion of a new IABP catheter.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Ensuring the IABP console is turned off is crucial to prevent further complications and stop potential harm to the patient.
2. By turning off the IABP console, the nurse can halt the pumping action, allowing assessment of the situation without interference.
3. This action takes priority over other steps as it addresses the immediate issue of blood backing up into the IABP catheter.
4. Once the console is turned off, the nurse can proceed with assessing the patient's vital signs, notifying the healthcare provider, and obtaining supplies if needed.
Summary of Incorrect Choices:
- Option B: Assessing vital signs and orientation is important, but addressing the malfunction of the IABP takes precedence to prevent harm.
- Option C: Notifying the healthcare provider is necessary, but first, the immediate issue of blood backing up into the catheter must be addressed.
- Option D: Obtaining supplies for a new catheter is premature without first addressing
As part of the Synergy Model, the nurse has identified a patient characteristic of resiliency. What patient behavior demonstrates resiliency?
- A. Dysfunctional grieving behaviors after receiving bad news
- B. Developing a list of questions for the physician
- C. Denial of any possible negative outcomes for a procedure
- D. Assigning blame to others for undesired outcomes of illness
Correct Answer: B
Rationale: The correct answer is B because developing a list of questions for the physician shows active engagement in their healthcare, seeking information, and taking control of their situation, which are characteristics of resiliency. This behavior indicates the patient's willingness to understand and cope with their health condition. Choices A, C, and D are incorrect as they demonstrate maladaptive coping mechanisms such as dysfunctional grieving, denial, and blame assignment, which are not indicative of resiliency. Resiliency involves adaptability, problem-solving, and seeking support, which are better exemplified by choice B.