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The assessment of pain and anxiety is a continuous proces s. When critically ill patients exhibit signs of anxiety, what is the nurse’s first priority?
- A. To administer antianxiety medications as ordered
- B. To administer pain medication as ordered
- C. To identify and treat the underlying cause
- D. To reassess the patient hourly to determine whether symptoms resolve on their own
Correct Answer: C
Rationale: The correct answer is C: To identify and treat the underlying cause. The first priority of the nurse when critically ill patients exhibit signs of anxiety is to determine the root cause of the anxiety. By identifying and addressing the underlying cause, the nurse can effectively manage the patient's anxiety and prevent further complications. Administering medications without understanding the cause can mask the symptoms and lead to ineffective treatment. Reassessing the patient hourly may not address the root cause and could delay appropriate intervention. Pain medication may not be necessary if the anxiety is not related to pain. Treating the underlying cause ensures holistic and effective care for the patient.
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The nurse uses the Situation-Background-Assessment-Recommendation (SBAR) format to communicate a change in patient status to a healthcare provider. In which order should the nurse make the following statements?
- A. The patient needs to be evaluated immediately and may need intubation and mechanical ventilation.
- B. The patient was admitted yesterday with heart failure and has been receiving furosemide (Lasix) for diuresis, but urine output has been low.
- C. The patient has crackles audible throughout the posterior chest and the most recent oxygen saturation is 89%. Her condition is very unstable.
- D. This is the nurse on the surgical unit. After assessing the patient, I am very concerned about increased shortness of breath over the past hour.
Correct Answer: B
Rationale: Step 1: Start with Background - statement B provides relevant background information about the patient's current condition and why there is a need for communication.
Step 2: Move on to Situation - statement D sets the current situation where the nurse expresses concern about the patient's symptom.
Step 3: Next is Assessment - statement C details the nurse's assessment findings, highlighting the critical aspects of the patient's condition.
Step 4: End with Recommendation - statement A suggests the necessary action to be taken based on the assessment findings. This order ensures a clear and structured communication process.
Summary:
- Choice A is incorrect as the recommendation should come after providing background, situation, and assessment.
- Choice C is incorrect as assessment details should precede the patient's critical condition.
- Choice D is incorrect as the situation should be explained before expressing concern.
The nurse observes that an elderly woman, whose granddaughter has been admitted to theICU, is struggling to manage her two great-grandsons, who are toddlers, in the waiting room. What is the most likely explanation for the womans inability to manage the children in this situation?
- A. She is senile.
- B. She is in the exhaustion stage of the general adaptation syndrome to stress.
- C. She is assuming the role of caregiver in place of the patient, a role she is not used to.
- D. She has macular degeneration and cannot see well.
Correct Answer: B
Rationale: The correct answer is B: She is in the exhaustion stage of the general adaptation syndrome to stress.
Rationale:
1. In the exhaustion stage, the body's resources are depleted due to prolonged stress, leading to fatigue and reduced ability to cope.
2. The elderly woman is likely experiencing high levels of stress due to her granddaughter's critical condition.
3. Managing toddlers while dealing with the emotional distress of a loved one in the ICU can be overwhelming, causing exhaustion.
4. This explanation aligns with the symptoms of fatigue and difficulty managing the children observed by the nurse.
Summary:
A: Incorrect. Senility is a cognitive condition unrelated to the stress of the situation.
C: Incorrect. Assuming a caregiver role can be stressful, but it does not explain the observed exhaustion.
D: Incorrect. Macular degeneration affects vision, not the ability to manage stress and children.
A 53-year-old, 80-kg patient is admitted to the cardiac sur gical intensive care unit after cardiac surgery with the following arterial blood gas (ABG ) levels. What is the nurse’s interpretation of these values? pH 7.4 PaCO 40 mm Hg Bicarbonate 24 mEq/L PaO 95 mm Hg O saturation 97% Respirations 20 breaths per minute
- A. Compensated metabolic acidosis
- B. Metabolic alkalosis
- C. Normal ABG values
- D. Respiratory acidosis
Correct Answer: C
Rationale: The correct interpretation is C: Normal ABG values.
1. pH is within the normal range of 7.35-7.45.
2. PaCO2 is 40 mm Hg, within the normal range of 35-45 mm Hg.
3. Bicarbonate is 24 mEq/L, within the normal range of 22-26 mEq/L.
4. PaO2 is 95 mm Hg, within the normal range of 80-100 mm Hg.
5. Oxygen saturation is 97%, which is normal.
6. Respirations are also within the normal range at 20 breaths per minute.
Overall, all values fall within the normal range, indicating a well-maintained acid-base balance. Other choices are incorrect because there are no abnormalities that would suggest compensated metabolic acidosis, metabolic alkalosis, or respiratory acidosis based on the given ABG values.
The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.)
- A. high Fowler’s.
- B. side lying with head of bed elevated.
- C. sitting in a chair.
- D. supine with the bed flat.
Correct Answer: A
Rationale: The correct answer is A: high Fowler's position. This position promotes optimal lung expansion by allowing the chest to expand fully, improving oxygenation. It also helps reduce the work of breathing. Side lying with the head of the bed elevated (B) may not provide the same level of lung expansion. Sitting in a chair (C) may not be suitable for a patient in acute respiratory failure as it may not provide adequate support for breathing. Supine with the bed flat (D) can worsen respiratory distress by limiting lung expansion.
Family assessment is essential in order to meet family nee ds. Which of the following must be assessed first to assist the nurse in providing family-centered care?
- A. Assessment of patient and family’s developmental stag es and needs
- B. Description of the patient’s home environment
- C. Identification of immediate family, extended family, a nd decision makers
- D. Observation and assessment of how family members fu nction with each other
Correct Answer: A
Rationale: The correct answer is A because assessing the patient and family's developmental stages and needs is crucial in understanding their current situation and determining the appropriate care plan. By assessing developmental stages, the nurse can tailor interventions to meet the family's specific needs. This assessment also helps in identifying potential challenges or areas requiring support.
Choice B is incorrect as it focuses solely on the physical environment and does not address the family's developmental stages and needs.
Choice C is incorrect as it emphasizes identifying family members without considering the importance of understanding their developmental stages and needs in providing family-centered care.
Choice D is incorrect as it concentrates on family dynamics without directly addressing the crucial aspect of assessing developmental stages and needs for effective family-centered care.