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The nurse is assessing the critically ill patient for delirium . The nurse recognizes which characteristics that indicate hyperactive delirium? (Select aabllir bt.hcaomt /atepstp ly.)
- A. Agitation
- B. Apathy
- C. Biting
- D. Hitting
Correct Answer: A
Rationale: The correct answer is A: Agitation. In hyperactive delirium, patients often exhibit restlessness, agitation, and hyperactivity. This behavior is a key characteristic indicating hyperactive delirium. Apathy (B), biting (C), and hitting (D) are not typically associated with hyperactive delirium. Apathy may be seen in hypoactive delirium, while biting and hitting are not specific indicators of delirium subtypes. Therefore, the correct choice is A as it aligns with the typical presentation of hyperactive delirium.
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A nurse is the only one in the ICU who has not achieved certification in critical care nursing. She often will ask her fellow nurses what to do in caring for a patient because she doubts the accuracy of her knowledge and her intuition. She loves her work but wishes she could do it with a greater level of competence. What is the most important effect that obtaining certification would likely have on the nurses practice?
- A. Recognition by peers
- B. Increase in salary and rank
- C. More flexibility in seeking employment
- D. Increased confidence in making decisions
Correct Answer: D
Rationale: The correct answer is D: Increased confidence in making decisions. Obtaining certification in critical care nursing would likely enhance the nurse's knowledge and skills, leading to increased confidence in making clinical decisions. This confidence would stem from the rigorous training and education required to achieve certification, as well as the validation of her expertise in critical care nursing. With increased confidence, the nurse would be more self-assured in her abilities, leading to improved patient care outcomes.
Choice A: Recognition by peers is not the most important effect because while recognition is a positive outcome, it may not directly impact the nurse's ability to provide better patient care.
Choice B: Increase in salary and rank is not the most important effect because while financial benefits are important, the primary focus of obtaining certification should be on improving competence and patient care.
Choice C: More flexibility in seeking employment is not the most important effect because while certification may open up more job opportunities, the main benefit should be on enhancing the nurse's skills and confidence in providing quality
Which action is a priority for the nurse to take when the low-pressure alarm sounds for a patient who has an arterial line in the left radial artery?
- A. Fast flush of the arterial line.
- B. Check the left hand for pallor.
- C. Assess for cardiac dysrhythmias.
- D. Rezero the monitoring equipment.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): When the low-pressure alarm sounds for a patient with an arterial line, the nurse should assess for cardiac dysrhythmias first. This is because a sudden drop in pressure could indicate a serious issue affecting the heart's ability to pump effectively. Identifying and addressing any cardiac dysrhythmias promptly is crucial for patient safety.
Summary of Incorrect Choices:
A: Fast flush of the arterial line - This would not address the underlying cause of the low-pressure alarm and may not be necessary.
B: Check the left hand for pallor - While assessing perfusion is important, it is not the priority when the alarm indicates a potential cardiac issue.
D: Rezero the monitoring equipment - While important for accuracy, it is not the priority when the alarm indicates a potential cardiac concern.
The removal of plasma water and some low–molecular weight particles by using a pressure or osmotic gradient is known as
- A. dialysis.
- B. diffusion.
- C. clearance.
- D. ultrafiltration.
Correct Answer: D
Rationale: Ultrafiltration is the correct answer because it involves the removal of plasma water and low-molecular weight particles by using a pressure or osmotic gradient. During ultrafiltration, the pressure gradient pushes the fluid through a semipermeable membrane, separating the substances based on their molecular size. This process allows for the selective removal of unwanted substances while retaining essential components. Dialysis (choice A) involves the removal of waste products from the blood, but it does not specifically target plasma water and low-molecular weight particles. Diffusion (choice B) is the passive movement of particles from an area of higher concentration to an area of lower concentration and is not specific to the removal of plasma water. Clearance (choice C) refers to the rate at which a substance is removed from the blood and does not involve the mechanism of pressure or osmotic gradient utilized in ultrafiltration.
The patient’s partner, experiencing anticipatory grieving, tells the nurse, “I don’t see any point in continuing to visit at the bedside, since it’s like I’m not even here.” What is the nurse’s best response to the partner’s statement?
- A. “You’re right, there is no awareness of anything going on now.”
- B. “Unresponsiveness doesn’t mean the sense of hearing is gone and there is a benefit from you being present.”
- C. “I’ll call you if the patient begins responding again.”
- D. “Why don’t you check to see if any other family memb er would like to visit?”
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the partner's feelings while providing information that may help them cope. By stating that unresponsiveness doesn't mean the patient can't hear, the nurse highlights the importance of the partner's presence for emotional support. It encourages the partner to continue visiting, emphasizing their role in providing comfort to the patient.
Choice A is incorrect as it dismisses the partner's feelings and lacks empathy. Choice C is incorrect as it implies the nurse will only involve the partner if the patient responds, neglecting the partner's emotional needs. Choice D is incorrect as it deflects responsibility from addressing the partner's concerns and suggests involving other family members without addressing the partner's feelings directly.
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.