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A nurse needs to communicate with a patients family regarding consent to treat an unconscious patient in the ICU. Which member of the group should the nurse approach first?
- A. A man she recognizes as the patients brother
- B. A teenage boy who approaches the nurse
- C. A woman who originally escorted the patient in
- D. A woman in the group whom the others look at and call over when the nurse approaches
Correct Answer: C
Rationale: The correct answer is C: A woman who originally escorted the patient in. This choice is correct because she is most likely the person responsible for the patient's care and thus likely has legal authority to make medical decisions on behalf of the patient. The other choices are incorrect because simply being recognized as the patient's brother (A), being a teenage boy who approaches the nurse (B), or being a woman whom the others look at and call over (D) does not necessarily indicate that they have the legal authority to make medical decisions for the unconscious patient.
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What is the basic underlying pathophysiology of acute respiratory distress syndrome?
- A. A decrease in the number of white blood cells availabl e.
- B. Damage to the right mainstem bronchus.
- C. Damage to the type II pneumocytes, which produce suarbfiarbc.tcaomnt/t.e st
- D. Decreased capillary permeability.
Correct Answer: C
Rationale: The correct answer is C: Damage to the type II pneumocytes, which produce surfactant. Acute respiratory distress syndrome (ARDS) is characterized by damage to the alveolar epithelium, including type II pneumocytes responsible for producing surfactant. Surfactant reduces surface tension in the alveoli, preventing collapse. Damage to type II pneumocytes impairs surfactant production, leading to alveolar collapse and impaired gas exchange. Choices A, B, and D are incorrect because ARDS is not primarily caused by a decrease in white blood cells, damage to the right mainstem bronchus, or decreased capillary permeability.
While waiting for cardiac transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. When planning care for this patient, the nurse should anticipate:
- A. Giving immunosuppressive medications.
- B. Preparing the patient for a permanent VAD.
- C. Teaching the patient the reason for complete bed rest.
- D. Monitoring the surgical incision for signs of infection.
Correct Answer: D
Rationale: The correct answer is D because monitoring the surgical incision for signs of infection is essential post-VAD implantation to prevent complications. This step is crucial in early identification and treatment of any potential infection, which can lead to serious outcomes.
A) Giving immunosuppressive medications is not typically required for VAD implantation, as the primary goal is to support cardiac function rather than prevent rejection.
B) Preparing the patient for a permanent VAD is premature, as the goal is often to bridge to transplantation or recovery, not permanent VAD placement.
C) Teaching the patient the reason for complete bed rest is not necessary for VAD implantation, as patients are typically encouraged to gradually increase activity levels under guidance.
A family of a young girl who has been diagnosed with leukemia has travelled 12 hours by car to admit her to the ICU and be with her during her treatment. Which aspect of the critical care family assistance program would most likely be needed by this family initially?
- A. Educational materials
- B. Weekly group family information sessions
- C. Hospitality programs
- D. Pet therapy
Correct Answer: C
Rationale: The correct answer is C: Hospitality programs. Given the family's long journey and the stressful situation of having a child diagnosed with leukemia, their immediate need would likely be for accommodations and support services provided by hospitality programs, such as lodging, meals, transportation assistance, and emotional support. This would help alleviate the burden of their travel and allow them to focus on being with their daughter in the ICU.
Incorrect answers:
A: Educational materials - While education is crucial for families, it may not be the most immediate need in this situation.
B: Weekly group family information sessions - These sessions may be helpful for support and information-sharing, but they are not as urgent as addressing the family's immediate needs.
D: Pet therapy - While pet therapy can provide emotional support, it may not be the most pressing need for this family at the moment.
When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate?
- A. Do you feel safe in your home?
- B. You should not return to your home.
- C. Would you like to see a social worker?
- D. I need to report my concerns to the police.
Correct Answer: A
Rationale: The correct answer is A: "Do you feel safe in your home?" This question is most appropriate because it directly addresses the potential issue of elder abuse without assuming or accusing the patient. It allows the patient to disclose any safety concerns and initiates a conversation about their well-being. Options B and D are inappropriate as they are accusatory and may escalate the situation. Option C is not as direct and may not effectively address the safety concerns of the patient.
A nurse is caring for a patient in the final stages of dying. What is the most appropriate nursing action?
- A. Encourage the patient to eat to maintain strength.
- B. Provide emotional support and comfort measures.
- C. Perform frequent assessments to monitor for recovery signs.
- D. Implement aggressive interventions to prolong life.
Correct Answer: B
Rationale: The correct answer is B: Provide emotional support and comfort measures. In the final stages of dying, the focus shifts from curative treatment to providing comfort and dignity. Emotional support helps alleviate anxiety and fear, promoting a peaceful transition. Comfort measures like pain management improve quality of life. Encouraging the patient to eat may be futile as the body shuts down. Performing frequent assessments for recovery signs is not appropriate in this situation. Implementing aggressive interventions could go against the patient's wishes for a natural death.