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A critically ill patient tells the nurse that he is not afraid to die because he believes in reincarnation. What is the most appropriate nursing response?
- A. What if reincarnation is not real?
- B. This belief gives you strength.
- C. I dont believe in reincarnation.
- D. You shouldnt base your hopes on such a belief.
Correct Answer: B
Rationale: The correct answer is B because it acknowledges and validates the patient's belief, showing empathy and support. By stating that the belief gives strength, the nurse facilitates a therapeutic relationship and promotes the patient's emotional well-being. Choice A is incorrect as it challenges the patient's belief system, potentially creating conflict. Choice C is inappropriate as it dismisses the patient's belief and could damage the nurse-patient relationship. Choice D is also incorrect as it invalidates the patient's belief and could harm trust and rapport.
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The nurse assesses a patient who is admitted for an overdo se of sedatives. The nurse expects to find which acid-base alteration?
- A. Hyperventilation and respiratory acidosis
- B. Hypoventilation and respiratory acidosis
- C. Hypoventilation and respiratory alkalosis
- D. Respiratory acidosis and normal oxygen levels
Correct Answer: B
Rationale: The correct answer is B: Hypoventilation and respiratory acidosis. When a patient overdoses on sedatives, it can lead to respiratory depression causing hypoventilation. Hypoventilation results in retention of CO2, leading to respiratory acidosis. This is because the body is not effectively exhaling CO2, causing an increase in carbonic acid levels and a decrease in blood pH. The other choices are incorrect because hyperventilation would lead to respiratory alkalosis (Choice A), hypoventilation does not cause respiratory alkalosis (Choice C), and normal oxygen levels do not indicate the acid-base imbalance caused by sedative overdose (Choice D).
When performing an initial pulmonary artery occlusion pr essure (PAOP), what are the best nursing actions? (Select all that apply.)
- A. Inflate the balloon for no more than 8 to 10 seconds w hile noting the waveform change.
- B. Inflate the balloon with air, recording the volume nece ssary to obtain a reading.
- C. Maintain the balloon in the inflated position for 8 hours following insertion.
- D. Zero reference and level the air-fluid interface of the tr ansducer at the level of the phlebostatic axis.
Correct Answer: A
Rationale: The correct answer is A: Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. This is because inflating the balloon within this time frame allows for accurate measurement of PAOP without causing complications like pulmonary edema. Noting the waveform change helps in determining the accurate pressure reading.
Explanation of why other choices are incorrect:
B: Inflating the balloon with air and recording the volume necessary is not a recommended practice as it can lead to inaccurate readings and potential harm to the patient.
C: Maintaining the balloon inflated for 8 hours following insertion is unnecessary and could lead to complications such as vascular damage or thrombosis.
D: Zero referencing and leveling the transducer at the phlebostatic axis are important steps but not directly related to performing an initial PAOP measurement.
The nurse understands that a patient being cared for in a critical care unit experiences anacute stress response. What nursing action best demonstrates understanding of the physiological parts of the initial stress response?
- A. Adequate pain control
- B. Intravenous sedation
- C. Treatment for elevated blood pressure
- D. Ignoring an elevated glucose level
Correct Answer: C
Rationale: The correct answer is C: Treatment for elevated blood pressure. In the initial stress response, the body releases adrenaline and cortisol, leading to increased heart rate and blood pressure. Treating elevated blood pressure is crucial to prevent complications like heart attack or stroke. Adequate pain control (A) and intravenous sedation (B) may help manage symptoms but do not directly address the physiological response to stress. Ignoring an elevated glucose level (D) is not recommended as stress can impact blood sugar levels. Treatment for elevated blood pressure directly targets the physiological response to stress, making it the best nursing action in this scenario.
The nurse is caring for a patient with severe neurological impairment following a massive stroke. The primary care provider has ordered tests to detearbmirbi.ncoem b/treasit n death. The nurse understands that criteria for brain death includes what crite ria? (Select all that apply.)
- A. Absence of cerebral blood flow.
- B. Absence of brainstem reflexes on neurological examin ation.
- C. Presents of Cheyne-Stokes respirations.
- D. Confirmation of a flat electroencephalogram.
Correct Answer: A
Rationale: The correct answer is A: Absence of cerebral blood flow. Brain death is determined by the irreversible cessation of all brain functions, including blood flow to the brain. When there is no cerebral blood flow, the brain is unable to function, leading to brain death. This criterion is essential in diagnosing brain death as it indicates a complete loss of brain function.
Explanation for why the other choices are incorrect:
- B: Absence of brainstem reflexes on neurological examination is a common sign of brain death, but it is not the primary criterion.
- C: Presence of Cheyne-Stokes respirations is not indicative of brain death. It is a pattern of breathing that can be seen in various conditions, not specifically brain death.
- D: Confirmation of a flat electroencephalogram is a supportive test for brain death but not the primary criterion. The absence of brain activity on an EEG can help confirm brain death but is not as definitive as the absence of cerebral blood flow.
Which statement is consistent with societal views of dying in the United States?
- A. Dying is viewed as a failure on the part of the system and providers.
- B. Most Americans would prefer to die in a hospital to spaabrireb .lcoomve/teds to nes the burden of care.
- C. People die of indistinct, complex illness for which a cu re is always possible.
- D. The purpose of the healthcare system is to prevent dise ase and treat symptoms.
Correct Answer: D
Rationale: Rationale: The correct answer is D because the purpose of the healthcare system in the United States is primarily focused on disease prevention and symptom management. This aligns with societal views as healthcare is geared towards improving health outcomes and quality of life.
Incorrect choices:
A: Dying is not viewed as a failure of the system or providers, rather as a natural part of life.
B: Most Americans prefer to die at home or in hospice care rather than in a hospital.
C: Illnesses are not always curable, and death can result from various complex conditions beyond treatment.