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A critically ill patient who is intubated and agitated is restrained with soft wrist restraints. Based on research findings, what is the best nursing action?
- A. Maintain the restraints to protect patient safety.
- B. Remove the restraints periodically to check skin integrity.
- C. Remove the restraints periodically for range of motion.
- D. Assess and intervene for causes of agitation. Answer Key
Correct Answer: D
Rationale: The correct answer is D: Assess and intervene for causes of agitation. In a critically ill patient, agitation while intubated could indicate underlying issues like pain, delirium, or inadequate sedation. By assessing and addressing the root cause of agitation, the nurse can improve patient comfort and prevent potential harm from restraints. Removing restraints periodically for skin integrity (B) and range of motion (C) is important but should not be the primary focus when agitation is present. Maintaining restraints (A) without addressing the agitation could lead to increased distress and potential complications.
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A patient who has been diagnosed with inoperable lung cancer and has a poor prognosis plans a trip across the country to settle some issues with their siblings. The nurse recognizes that the patient is manifesting which psychosocial response to death?
- A. Restlessness.
- B. Yearning and protest.
- C. Anxiety about unfinished business.
- D. Fear of the meaninglessness of one’s life.
Correct Answer: C
Rationale: The correct answer is C: Anxiety about unfinished business. The patient's desire to settle issues with their siblings before death indicates a concern about unresolved matters. This response aligns with the concept of psychosocial responses to death, specifically the need for closure and resolution. Restlessness (choice A) may not necessarily indicate a specific focus on unfinished business. Yearning and protest (choice B) typically refer to the initial stages of grief, not specifically related to settling unresolved issues. Fear of the meaninglessness of one's life (choice D) is more existential and philosophical, whereas the patient's focus here is on addressing specific issues with their siblings.
The nurse manager recognizes which action as an effectiveab sirtbr.acotmeg/teys tf or promoting changes in practice?
- A. Asking the clinical nurse specialist to lead a journal clu b on open visitation after each nurse is tasked to read one research article about visitation.
- B. Discussing pros and cons of open visitation at the next staff meeting.
- C. Inviting the nurses with the most experience to develop a revised policy.
- D. Tasking the unit-based nurse practice council to invite volunteers to serve on the council to revise the current policy toward more liberaal bviribs.ciotamt/iteosnt .
Correct Answer: A
Rationale: The correct answer is A because it involves a structured approach to promoting changes in practice. By asking the clinical nurse specialist to lead a journal club on open visitation after each nurse reads a research article, it ensures that all nurses are informed and engaged in the topic. This approach promotes evidence-based practice and encourages active participation.
Option B is less effective as discussing pros and cons at a staff meeting may not ensure that all nurses have the necessary knowledge to make informed decisions. Option C may not consider diverse perspectives and may not involve all staff members equally. Option D involves a select group of volunteers and may not reflect the views of the entire team. Overall, option A is the most inclusive and educational approach to promoting changes in practice.
An Ethiopian man with AIDS has recently been admitted to the ICU with a case of pneumonia. The man is new to the U.S. and has no health insurance. He would likely be eligible for the states Medicaid coverage, but does not understand how to access this coverage. Which competency or competencies are most needed in this situation? Select all that apply.
- A. Clinical judgment
- B. Advocacy and moral agency
- C. Collaboration
- D. Systems thinking
Correct Answer: B
Rationale: The correct answer is B: Advocacy and moral agency. In this scenario, the Ethiopian man with AIDS is in a vulnerable position due to lack of health insurance and understanding of Medicaid coverage. Advocacy skills are crucial to help him navigate the complex healthcare system and access the necessary resources. Moral agency involves advocating for the patient's rights and well-being, ensuring that he receives appropriate care despite his socioeconomic status. Clinical judgment, collaboration, and systems thinking are important competencies but not as directly relevant in this specific situation of advocating for the patient's access to Medicaid coverage.
The nurse is concerned that the patient will pull out the en dotracheal tube. As part of the nursing management, the nurse should obtain an order for what intervention?
- A. A Posey-type vest
- B. A higher dosage of lorazepam
- C. Propofol
- D. Soft wrist restraints
Correct Answer: A
Rationale: The correct answer is A. A Posey-type vest is a restraint designed to prevent patients from pulling out medical devices like endotracheal tubes, ensuring their safety. It is a less restrictive option compared to wrist restraints and sedatives (B and C), which can have adverse effects and may not directly address the concern of tube removal. Using a Posey-type vest promotes patient autonomy by allowing some movement while still providing the necessary protection.
The nurse is discussing the role of hospice care with a patient and family. Which statement by the nurse accurately describes hospice care?
- A. Hospice care aims to cure serious illnesses through specialized treatments.
- B. Hospice care provides support and comfort for patients at the end of life.
- C. Hospice care is only for patients with cancer-related illnesses.
- D. Hospice care focuses primarily on extending life expectancy.
Correct Answer: B
Rationale: The correct answer is B because hospice care indeed focuses on providing support and comfort for patients at the end of life. This is achieved through pain management, emotional support, and enhancing quality of life. Choice A is incorrect because hospice care does not aim to cure serious illnesses but rather to provide comfort and care. Choice C is incorrect as hospice care is not limited to patients with cancer but is available to individuals with various terminal illnesses. Choice D is incorrect as hospice care does not focus on extending life expectancy but rather on improving the quality of life during the end-of-life period.