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An unresponsive 79-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient’s core temperature is 105.4°F (40.8°C), blood pressure (BP) 88/50, and pulse 112. The nurse initially will plan to:
- A. Apply wet sheets and a fan to the patient.
- B. Provide O2 at 6 L/min with a nasal cannula.
- C. Start lactated Ringer's solution at 1000 mL/hr.
- D. Give acetaminophen (Tylenol) rectal suppository.
Correct Answer: A
Rationale: The correct answer is A: Apply wet sheets and a fan to the patient. This is the initial treatment for hyperthermia to aid in lowering the body temperature. Wet sheets help in evaporative cooling, while a fan enhances heat loss through convection. This approach is crucial in managing heat-related illnesses quickly. Choices B, C, and D are incorrect as they do not directly address the urgent need to reduce the patient's elevated core temperature. Providing O2, IV fluids, or acetaminophen can be considered later in the management, but the priority is to rapidly lower the body temperature in a hyperthermic patient to prevent further complications.
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The family members of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take next?
- A. Explain ICU visitation policies and encourage family visits.
- B. Immediately take the family members to the patient’s bedside.
- C. Describe the patient’s injuries and the care that is being provided.
- D. Invite the family to participate in a multidisciplinary care conference.
Correct Answer: A
Rationale: The correct answer is A: Explain ICU visitation policies and encourage family visits. This is the best course of action because it prioritizes the needs of the family members by providing them with information on visitation policies and encouraging them to visit the patient. This helps establish communication, support, and involvement in the patient's care. It also respects the family's emotional needs during a challenging time.
Choices B, C, and D are incorrect:
B: Immediately taking the family members to the patient's bedside may overwhelm them and disrupt the patient's care.
C: Describing the patient's injuries and care being provided should be done in a more controlled environment to ensure the family's understanding and emotional readiness.
D: Inviting the family to a multidisciplinary care conference may be premature without first addressing their immediate concerns and providing support.
What is a strategy for preventing thromboembolism in pat ients at risk who cannot take anticoagulants?
- A. Administration of two aspirin tablets every 4 hours.
- B. Infusion of thrombolytics.
- C. Insertion of a vena cava filter.
- D. Subcutaneous heparin administration every 12 hours.
Correct Answer: C
Rationale: The correct answer is C: Insertion of a vena cava filter. This is a strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants. The vena cava filter prevents blood clots from traveling to the lungs by trapping them in the inferior vena cava. It is a mechanical device that does not interfere with the body's clotting process.
Explanation of why other choices are incorrect:
A: Administration of two aspirin tablets every 4 hours is not an effective strategy for preventing thromboembolism in high-risk patients. Aspirin is an antiplatelet agent and may not be sufficient for preventing blood clots in these patients.
B: Infusion of thrombolytics is used for breaking down blood clots that have already formed, not for prevention. It is not a suitable option for preventing thromboembolism in at-risk patients.
D: Subcutaneous heparin administration every 12
A statement that provides a legally recognized descriptiona obifrb a.cno min/tedsitv idual’s desires regarding care at the end of life is referred to as what?
- A. Advance directive
- B. Guardianship ad item
- C. Healthcare proxy
- D. Power of attorney
Correct Answer: A
Rationale: The correct answer is A: Advance directive. An advance directive is a legal document that outlines a person's wishes regarding medical treatment and care at the end of life. It allows individuals to specify their preferences for medical interventions if they become unable to communicate.
Summary of other choices:
B: Guardianship ad item - This does not specifically pertain to an individual's end-of-life care wishes.
C: Healthcare proxy - While similar to an advance directive, a healthcare proxy specifically designates a person to make medical decisions on behalf of the individual, rather than specifying their own wishes.
D: Power of attorney - This grants someone the authority to make legal decisions on behalf of the individual, but it does not specifically address end-of-life care preferences.
Which of the following factors predispose the critically ill patient to pain and anxiety? (Select all that apply.)
- A. Inability to communicate
- B. Invasive procedures
- C. Monitoring devices
- D. Preexisting conditions
Correct Answer: A
Rationale: The correct answer is A: Inability to communicate. Critically ill patients often experience pain and anxiety due to their inability to effectively communicate their needs and discomfort. This can lead to unaddressed pain and increased anxiety levels. Choices B, C, and D are incorrect because while invasive procedures, monitoring devices, and preexisting conditions can contribute to pain and anxiety in critically ill patients, they are not factors that directly predispose patients to these issues. It is the lack of communication that significantly hinders the ability to address and manage pain and anxiety effectively in these patients.
A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
- A. Has the client experienced constipation recently?
- B. Did the client miss any doses of the medication?
- C. How long has the client been taking the medication?
- D. Does the client use any tobacco products?
Correct Answer: C
Rationale: The correct answer is C. Assessing how long the client has been taking clonidine is crucial as drowsiness is a common side effect that typically improves over time as the body adjusts to the medication. This information helps determine if the drowsiness is a temporary side effect or a more concerning issue.
Choice A (constipation) is not directly related to drowsiness as a side effect of clonidine. Choice B (missed doses) may contribute to drowsiness but is not the primary assessment priority. Choice D (tobacco use) is not directly related to clonidine-induced drowsiness.