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On their first visit to a critically ill patient, family members stand in the doorway of the room, making no effort to approach the patient. What is the most appropriate nursing action?
- A. Instruct the family where the patient can be touched and what to say.
- B. Engage the family in social conversation to ease them into the milieu.
- C. Use visiting hours to explain to the family the general status of the patient.
- D. Leave the family to adjust to the situation when they are ready.
Correct Answer: A
Rationale: The correct answer is A because instructing the family on where the patient can be touched and what to say helps empower them to interact appropriately with the patient. This action promotes the family's involvement in the patient's care, encourages communication, and fosters a supportive environment. Choice B is incorrect as engaging in social conversation may not address the family's hesitance to approach the patient directly. Choice C is incorrect because waiting for visiting hours to provide information may delay necessary support for the family. Choice D is incorrect as leaving the family without guidance may perpetuate their discomfort and hinder their ability to provide emotional support to the patient.
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The critical care unit environment is very stressful for patients, families, and staff. What nursing action is directed at reducing environmental stress?
- A. Constant expert evaluation of patient status
- B. Limiting visits to immediate family
- C. Bathing all patients during hours of sleep
- D. Maintaining a quiet environment during hours of sleep
Correct Answer: D
Rationale: The correct answer is D: Maintaining a quiet environment during hours of sleep. This action is directed at reducing environmental stress in the critical care unit because noise and disturbances during sleep can negatively impact patients' rest and recovery. By ensuring a quiet environment, patients can have uninterrupted sleep, which is crucial for healing.
Rationale:
1. Constant expert evaluation of patient status (A) may be important but does not directly address environmental stress.
2. Limiting visits to immediate family (B) may hinder patients' emotional support and can be stressful for families.
3. Bathing all patients during hours of sleep (C) may disrupt patients' rest and increase stress levels rather than reduce it.
A family member approaches the nurse caring for their gra vely ill son and states, “We want to donate our son’s organs.” What is the best action by the nu rse?
- A. Arrange a multidisciplinary meeting with physicians.
- B. Consult the hospital’s ethics committee for a ruling.
- C. Notify the organ procurement organization (OPO).
- D. Obtain family consent to withdraw life support.
Correct Answer: C
Rationale: The correct answer is C: Notify the organ procurement organization (OPO). This is the best action because the OPO is responsible for coordinating organ donation and transplantation. By involving the OPO, the nurse ensures that the donation process is handled appropriately and ethically.
Choice A: Arranging a multidisciplinary meeting with physicians may be necessary but should not be the first step in this situation.
Choice B: Consulting the hospital’s ethics committee may be helpful, but the immediate priority is to involve the OPO to facilitate organ donation.
Choice D: Obtaining family consent to withdraw life support is not the nurse’s role in this situation. The focus should be on organ donation to honor the family's wishes.
Which of the following statements regarding pain and anxiety are true? (Select all that apply.)
- A. Anxiety is a state marked by apprehension, agitation, a utonomic arousal, and/or fearful withdrawal.
- B. Critically ill patients often experience anxiety, but they rarely experience pain.
- C. Pain and anxiety are often interrelated and may be diffaibciurbl.tc otmo /tdeisft ferentiate because their physiological and behavioral manifestations are similar.
- D. Pain is defined by each patient; it is whatever the perso n experiencing the pain says it is.
Correct Answer: A
Rationale: Rationale:
A: Correct. Anxiety is characterized by apprehension, agitation, autonomic arousal, and fearful withdrawal, which are distinct from pain.
B: Incorrect. Critically ill patients can experience both anxiety and pain, as pain is not exclusive to them.
C: Incorrect. While pain and anxiety can be interrelated, they can be differentiated based on their unique physiological and behavioral manifestations.
D: Incorrect. Pain is a subjective experience, but it is not solely defined by the individual; objective assessments are also important.
Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.)
- A. Exercise
- B. Hypovolemia
- C. Myocardial infarction
- D. Shock
Correct Answer: B
Rationale: Certainly. Hypovolemia, or low blood volume, can lead to low cardiac output and cardiac index because the heart has less blood to pump, resulting in reduced circulation. Exercise typically increases cardiac output to meet increased demand. Myocardial infarction may reduce cardiac output temporarily, but not consistently. Shock, a condition where the body's tissues do not receive enough oxygen and nutrients, can lead to low cardiac output, making it a possible cause.
A patient’s vital signs are pulse 87, respirations 24, BP of 128/64 mm Hg, and cardiac output is 4.7 L/min. The patient’s stroke volume is ______ mL. (Round to the nearest whole number.)
- A. 54
- B. 64
- C. 74
- D. 84
Correct Answer: A
Rationale: The stroke volume is calculated by dividing the cardiac output by the heart rate. Given the cardiac output of 4.7 L/min and a heart rate of 87 bpm, the stroke volume is 54 mL (4700 mL/87 bpm ≈ 54 mL). Therefore, choice A (54) is the correct answer. Choices B, C, and D are incorrect as they do not match the calculated stroke volume based on the provided cardiac output and heart rate.