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A middle-aged patient tells the nurse, 'My mother died 4 months ago, and I just can’t seem to get over it. I’m not sure it is normal to still think about her every day.' Which nursing diagnosis is most appropriate?
- A. Hopelessness related to the inability to resolve grief.
- B. Complicated grieving related to unresolved issues.
- C. Anxiety related to lack of knowledge about normal grieving.
- D. Chronic sorrow related to ongoing distress about the loss of a mother.
Correct Answer: C
Rationale: The correct answer is C: Anxiety related to lack of knowledge about normal grieving. This is because the patient is expressing uncertainty and seeking validation for their feelings, indicating a lack of understanding about the grieving process. Choice A is incorrect as hopelessness typically involves feelings of despair and loss of motivation, which are not explicitly stated by the patient. Choice B is incorrect as complicated grieving involves specific unresolved issues related to the loss, which the patient did not mention. Choice D is incorrect as chronic sorrow is typically associated with ongoing feelings of sadness and longing, which are not explicitly expressed by the patient.
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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.
After a change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first?
- A. Patient who failed a spontaneous breathing trial and has been placed in rest mode on the ventilator.
- B. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring.
- C. Patient with central venous oxygen saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP).
- D. Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours.
Correct Answer: D
Rationale: The correct answer is D - Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours. This patient should be assessed first because the absence of urine output for 6 hours after being extubated could indicate acute kidney injury or other serious complications that need immediate attention. Urine output is a crucial indicator of renal function and can reflect the patient's overall hemodynamic status. In contrast, the other choices do not present immediate life-threatening conditions. Choice A involves a patient in rest mode post-failed breathing trial, which does not require immediate assessment. Choice B mentions continuous PETCO2 monitoring, which is important but not as urgent as assessing a patient with no urine output. Choice C describes a patient with a ScvO2 of 69%, which may need monitoring but does not indicate an urgent priority compared to assessing a patient with no urine output after recent extubation.
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.
What does pulse oximetry measure?
- A. Arterial blood gases
- B. Hemoglobin values
- C. Oxygen consumption
- D. Oxygen saturation
Correct Answer: D
Rationale: Pulse oximetry measures oxygen saturation in the blood by analyzing the absorption of light by hemoglobin. Oxygen saturation indicates the percentage of hemoglobin molecules carrying oxygen. This is essential for assessing respiratory function and oxygen delivery to tissues. Arterial blood gases (Choice A) directly measure oxygen and carbon dioxide levels in the blood, not specifically oxygen saturation. Hemoglobin values (Choice B) provide information about the amount of hemoglobin present but not its oxygen-carrying capacity. Oxygen consumption (Choice C) is a measure of how much oxygen is used by tissues, not what pulse oximetry directly measures.
When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse manager will plan to obtain adequate quantities of:
- A. Vaccine.
- B. Atropine.
- C. Antibiotics.
- D. Whole blood.
Correct Answer: A
Rationale: The correct answer is A: Vaccine. Smallpox is a contagious and potentially deadly disease caused by the variola virus. The smallpox vaccine is the most effective way to prevent and control the spread of smallpox. By obtaining adequate quantities of the smallpox vaccine, the ED nurse manager can protect healthcare workers and the public from contracting the virus in case of a smallpox bioterrorism event. Atropine (B) is used to treat certain types of nerve agent poisoning, not smallpox. Antibiotics (C) are ineffective against viruses like smallpox. Whole blood (D) is not specifically needed for smallpox treatment.