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Family members are in the patient’s room when the patient has a cardiac arrest and the staff starts resuscitation measures. Which action should the nurse take next?
- A. Keep the family in the room and assign a staff member to explain the care given and answer questions.
- B. Ask the family to wait outside the patient’s room with a designated staff member to provide emotional support.
- C. Ask the family members whether they would prefer to remain in the patient’s room or wait outside the room.
- D. Tell the family members that patients are comforted by having family members present during resuscitation efforts.
Correct Answer: C
Rationale: The correct answer is C because it involves patient-centered care and respects the family's preferences. By asking the family members whether they would prefer to remain in the patient's room or wait outside, the nurse acknowledges their needs and allows them to make an informed decision based on their comfort level. This empowers the family members and promotes a supportive environment during a stressful situation.
Choice A is incorrect because it assumes that keeping the family in the room without their input is the best approach, which may not be the case for all families. Choice B is incorrect because asking the family to wait outside without considering their preferences may not be the most supportive action. Choice D is incorrect because it makes a blanket statement about patient comfort without considering individual family dynamics and preferences.
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Noise in the critical care unit can have negative effects on the patient. Which of the following interventions assists in reducing noise levels in the criticala cbiarbr.ec osme/ttetisnt g? (Select all that apply.)
- A. Asking the family to bring in the patient’s i-Pod or other device with favorite music.
- B. Inviting the volunteer harpist to play on the unit on a re gular basis.
- C. Remodeling the unit to have two-patient rooms to facil itate nursing care.
- D. Remodeling the unit to install acoustical ceiling tiles.
Correct Answer: A
Rationale: Step 1: Bringing in the patient's i-Pod with favorite music can provide personalized, soothing sounds, reducing stress and anxiety for the patient.
Step 2: Familiar music can create a calming environment, distracting the patient from external noise.
Step 3: Listening to music may improve patient comfort and overall experience in the critical care unit.
Summary: Option A is correct as it directly addresses noise reduction by providing a personalized, calming environment for the patient. Options B, C, and D do not specifically target noise reduction but focus on other aspects of care or facility improvement.
The nurse is caring for a patient diagnosed with hyperactivaebi rdb.ecloimri/tuemst . The nurse focuses interventions toward which priority need?
- A. Comfort
- B. Nourishment
- C. Safety
- D. Sedation
Correct Answer: C
Rationale: The correct answer is C: Safety. In hyperactive delirium, the patient may be agitated, disoriented, and at risk of harm. Safety is the priority to prevent falls or injury. Comfort (A) is important but secondary to safety in this case. Nourishment (B) can wait until safety is ensured. Sedation (D) may be considered but only after safety measures are in place.
The condition of a critically ill patient with a living will has deteriorated. The patient’s partner wants “everything done,” regardless of the patient’s wishe s. Which ethical principle is the partner violating?
- A. Autonomy
- B. Beneficence
- C. Justice
- D. Nonmaleficence
Correct Answer: A
Rationale: The correct answer is A: Autonomy. Autonomy is the ethical principle that respects an individual's right to make decisions about their own care and treatment. In this scenario, the partner wanting "everything done" regardless of the patient's wishes violates the patient's autonomy by not honoring their previously expressed wishes outlined in the living will. This decision disregards the patient's right to make choices about their own healthcare. Choices B, C, and D are incorrect because:
B: Beneficence focuses on doing good for the patient, but in this case, the partner's actions are not necessarily in the patient's best interest.
C: Justice pertains to fairness and equal treatment, which is not directly relevant to the situation described.
D: Nonmaleficence is the principle of doing no harm, but in this scenario, the harm is not necessarily physical but rather a violation of the patient's autonomy.
Critical illness often results in family conflicts. Which scenario is most likely to result in the greatest conflict?
- A. A 21-year-old college student of divorced parents hosp italized with multiple trauma. She resides with her mother. The parents are amicable with each other and have similar values. The father blames the daughter’s b oyfriend for causing the accident.
- B. A 36-year-old male admitted for a ruptured cerebral an eurysm. He has been living with his 34-year-old girlfriend for 8 years, and they have a 4-year-old daughter. He does not have written advance directives. His parents aarbriribv.ceo mfr/otemst out-of-state and are asked to make decisions about his health care. He h as not seen them in over a year.
- C. A 58-year-old male admitted for coronary artery bypas s surgery. He has been living with his same-sex partner for 20 years in a committed relationship. He has designated his sister, a registered nurse, as his healthca re proxy in a written advance directive.
- D. A 78-year-old female admitted with gastrointestinal blaebeirdbi.cnogm./ tHeset r hemoglobin is decreasing to a critical level. She is a Jehovah’s Witness and refuses the treatment of a blood transfusion. She is capable of making her ow n decisions and has a clearly written advance directive declining any transfu sions. Her son is upset with her and tells her she is “committing suicide.”
Correct Answer: D
Rationale: The correct answer is D because it involves a conflict between the patient's autonomy and her son's beliefs. The patient, a Jehovah's Witness, has clearly stated her refusal of a blood transfusion in her advance directive, which aligns with her religious beliefs. Her son's disagreement with her decision creates a significant ethical dilemma and conflict. This scenario highlights the clash between respecting the patient's autonomy and the son's concerns for her well-being.
Choice A is less likely to result in the greatest conflict as both parents have similar values and are amicable, with the conflict being directed towards the daughter's boyfriend.
Choice B involves a conflict between the patient's girlfriend and parents, but the patient's lack of advance directives and estranged relationship with his parents do not present as significant a conflict as in the correct answer.
Choice C involves a designated healthcare proxy and a committed relationship, which are less likely to result in a conflict as compared to the clash of beliefs and autonomy seen in Choice D.
An 81-year-old patient who has been in the intensive care unit (ICU) for a week is now stable, and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to:
- A. Give PRN lorazepam (Ativan) and cancel the transfer.
- B. Inform the receiving nurse and then transfer the patient.
- C. Notify the health care provider and postpone the transfer.
- D. Obtain an order for restraints as needed and transfer the patient.
Correct Answer: C
Rationale: The correct answer is C: Notify the health care provider and postpone the transfer. The new onset confusion in an elderly patient in the ICU can be a sign of delirium, which is a serious condition that requires prompt evaluation and management. By notifying the healthcare provider, they can assess the patient's condition, order appropriate tests, and adjust the treatment plan as needed. Postponing the transfer allows for further observation and intervention to address the underlying cause of the confusion.
Choice A (Give PRN lorazepam and cancel the transfer) is incorrect because administering lorazepam may worsen the confusion in an elderly patient and should not be done without proper evaluation.
Choice B (Inform the receiving nurse and then transfer the patient) is incorrect because transferring the patient without addressing the new onset confusion can lead to potential complications and delay in appropriate management.
Choice D (Obtain an order for restraints as needed and transfer the patient) is incorrect because using restraints should only be considered as a