Nokea
A nurse caring for a patient in the intensive care unit (ICU) implements strategies to create an environment conducive to sleep. Which strategy would be most effective?
- A. Turning off the lights in the room during the night
- B. Having the television on at all times for background noise
- C. Silencing the alarms on the bedside monitor and infusion pumps
- D. Administering ordered analgesics around the clock, even if the patient denies pain
Correct Answer: A
Rationale: The correct answer is A. Turning off the lights minimizes disruption to the patient's circadian rhythm. Background noise (B) and silencing alarms (C) may not always be feasible, and unnecessary analgesics (D) could interfere with sleep.
You may also like to solve these questions
What precaution should a nurse take to minimize the risk of death when using potassium chloride to flush a lock or central venous catheter?
- A. Use a dilute form of potassium chloride before flushing locks.
- B. Warm the potassium chloride before flushing locks.
- C. Document on the client’s chart.
- D. Ask the client to implement the instruction.
Correct Answer: A
Rationale: The correct answer is A because concentrated potassium chloride can cause cardiac arrest if injected rapidly.
A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?
- A. Increased respiratory rate from 18 to 44/min
- B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F)
- C. Increased blood pressure from 112/68 to 120/72 mm Hg
- D. Increased heart rate from 68 to 72/min
Correct Answer: A
Rationale: Step 1: Increased respiratory rate from 18 to 44/min indicates potential respiratory distress, a serious complication post-fracture.
Step 2: Rapid breathing can signify hypoxemia, pulmonary embolism, or infection, requiring immediate intervention.
Step 3: Increased oral temperature and blood pressure within normal range are not as critical as respiratory distress.
Step 4: A slight increase in heart rate is common after a fracture and not indicative of a serious complication.
Cognitive changes include memory problems, confusion, and disorientation. These changes:
- A. Occur in 75% of patients over age 65
- B. Are not a normal part of aging
- C. Are due to enhanced cerebral blood flow
- D. Cause senile plaques and neurofibrillary tangles
Correct Answer: B
Rationale: Cognitive decline is not a normal part of aging; it may indicate underlying conditions such as dementia or Alzheimer's disease. Normal aging involves mild forgetfulness but not significant impairment.
Following treatment with fluoxetine, a selective serotonin reuptake inhibitor for depression, Mary hardly sleeps, is hyperactive, easily distracted, and appears elated. You would expect her physician to
- A. Continue the selective serotonin reuptake inhibitor.
- B. Start a mood stabilizer.
- C. Switch to a tricyclic antidepressant.
- D. Add a monoamine oxidase inhibitor.
Correct Answer: B
Rationale: Mood stabilizers are used to treat symptoms of mania or hypomania associated with bipolar disorder.
Which physical assessment finding should be reported to the physician?
- A. Pearly gray or pink tympanic membrane
- B. Dense, whitish ring at the circumference of the tympanum
- C. Bulging red or blue tympanic membrane
- D. A cone of light at the innermost part of the tympanum
Correct Answer: C
Rationale: A bulging red or blue tympanic membrane indicates acute otitis media or other serious conditions requiring medical intervention.