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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 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.
A nurse who plans care based on the patient’s gender, ethn ai bc iri bt .y co, ms /p tei sr ti tuality, and lifestyle is said to demonstrate what focus?
- A. Becoming a moral advocate.
- B. Facilitating all forms of learning.
- C. Responding to diversity.
- D. Using effective clinical judgment.
Correct Answer: C
Rationale: The correct answer is C: Responding to diversity. By considering the patient's gender, ethnicity, spirituality, and lifestyle, the nurse is focusing on responding to diversity in patient care. This approach acknowledges and respects the unique characteristics and backgrounds of individual patients, leading to more culturally competent and effective care.
Choice A: Becoming a moral advocate does not directly relate to considering diversity in patient care. It involves standing up for ethical principles and values in healthcare.
Choice B: Facilitating all forms of learning is not specific to addressing diversity in patient care. It pertains to promoting education and understanding in various learning styles.
Choice D: Using effective clinical judgment is important in nursing practice but does not specifically address the focus on diversity in patient care. It pertains to making sound decisions based on clinical knowledge and expertise.
During a client assessment, the client says, 'I can't walk very well.' Which action should the nurse implement first?
- A. Predict the likelihood of the outcome.
- B. Consider alternatives.
- C. Choose the most successful approach.
- D. Identify the problem.
Correct Answer: D
Rationale: The correct answer is D: Identify the problem. This is the first action the nurse should take in the nursing process as it helps in understanding the client's issue. By identifying the problem, the nurse can gather more information through further assessment to determine the underlying cause of the client's difficulty in walking. This step is crucial for developing an effective care plan and interventions.
A: Predict the likelihood of the outcome - This choice is not appropriate as predicting the outcome should come after identifying the problem and implementing interventions.
B: Consider alternatives - While considering alternatives is important in the decision-making process, it is not the immediate action needed in this scenario.
C: Choose the most successful approach - This choice is premature as the nurse needs to first identify the problem before determining the most successful approach.
Which statement is true regarding the effects of caring for dying patients on nurses?
- A. Attendance at funerals is inappropriate and will only c reate additional stress in nurses who are already at risk for burnout.
- B. Caring for dying patients is an expected part of nursingab airnb.dco wm/itells tn ot affect the emotional health of the nurse if he or she maintains a p rofessional approach with each patient and family.
- C. Most nurses who work with dying patients are able to balance care needs of patients with personal emotional needs.
- D. Provision of aggressive care to patients for whom they believe it is futile may result in personal ethical conflicts and burnout for nurses.
Correct Answer: D
Rationale: The correct answer, D, is supported by the fact that providing aggressive care to patients when nurses believe it is futile can lead to personal ethical conflicts and burnout. This is because nurses may experience moral distress when their values conflict with the care they are providing. This can result in emotional exhaustion and decreased job satisfaction, ultimately leading to burnout.
Choice A is incorrect because attending funerals can be a way for nurses to process their grief and find closure, rather than creating additional stress. Choice B is incorrect because caring for dying patients can have emotional impacts on nurses, regardless of their professional approach. Choice C is incorrect because balancing care needs with personal emotional needs can be challenging and may not always be achievable.
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.