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The client has been in the CCU for several weeks and has been very unstable. One family member stays at the bedside constantly and even naps in a bedside chair. The nurse understands that the family member is exhibiting which family member response to critical illness?
- A. Exhibiting extreme distrust of the health care team
- B. Seeking evidence for future legal or punitive action
- C. Trying to maintain a level of control over the situation
- D. Experiencing extreme fatigue from constant stress
Correct Answer: C
Rationale: The correct answer is C: Trying to maintain a level of control over the situation. The family member staying at the bedside constantly and even napping there is likely trying to cope with the stressful situation by maintaining a sense of control and connection to the patient. This behavior can be a way for the family member to feel more involved and helpful during a time of uncertainty and powerlessness. Choices A and B involve negative assumptions about the family member's intentions without evidence. Choice D may be a result of the family member's actions but does not address the underlying motivation for their behavior.
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The transplant clinic coordinator is evaluating relatives of a patient with end-stage renal disease, whose blood type is A positive, for suitability as aa bliirvb.icnogm /dteostn or for kidney transplantation. Which family member best qualifies for evaluation?
- A. A 65-year-old brother with a history of hypertension; b lood type A positive
- B. A 35-year-old female with a history of food allergies; blood type O negative
- C. A 14-year-old son, otherwise healthy with no history; blood type B negative
- D. A 70-year-old mother, with a history of sinus infection s; blood type A positive
Correct Answer: D
Rationale: The correct answer is D, the 70-year-old mother with blood type A positive. This choice is the best candidate for evaluation due to her blood type matching the patient's (A positive) for kidney transplantation. Age and medical history are also crucial factors in determining suitability. The 65-year-old brother (choice A) has hypertension, a significant risk factor. The 35-year-old female (choice B) with food allergies may have potential complications. The 14-year-old son (choice C) is underage and might not be a suitable donor due to age and the potential impact on his growth and development. In summary, choice D aligns with the matching blood type and age, making the mother the most suitable candidate for evaluation.
A 22-year-old patient who experienced a near-drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?
- A. Auscultate heart sounds.
- B. Palpate peripheral pulses.
- C. Auscultate breath sounds.
- D. Check pupil reaction to light.
Correct Answer: C
Rationale: The correct answer is C: Auscultate breath sounds. After a near-drowning incident, the main concern is potential respiratory complications such as aspiration pneumonia or pulmonary edema. Auscultating breath sounds will help the nurse assess for any signs of respiratory distress or complications. This assessment is crucial for early detection and intervention.
A: Auscultating heart sounds is important but not as crucial as assessing breath sounds in this scenario.
B: Palpating peripheral pulses is important for circulation assessment but does not address the immediate concern of respiratory complications.
D: Checking pupil reaction to light is more relevant for neurological assessment and not as critical as assessing breathing in this situation.
A nurse walks into a patients room and begins preparing a syringe to perform a blood draw on the patient. The nurse observes that the patient is firmly gripping the side of the bed, averting her eyes, and sweating from her forehead when she sees the needle. What would be the best intervention for the nurse to make?
- A. Proceed with blood draw as quickly as possible, to get it over with.
- B. Offer to come back later to perform the blood draw.
- C. Encourage the patient to deep breathe.
- D. Describe briefly the blood draw procedure and explain why it is necessary.
Correct Answer: D
Rationale: The correct answer is D because it shows empathy and promotes patient education. By describing the procedure and its necessity, the nurse can alleviate the patient's anxiety and build trust. This approach allows the patient to feel informed and in control, reducing fear and increasing cooperation. It also demonstrates respect for the patient's feelings and promotes a therapeutic relationship.
Choice A is incorrect as it disregards the patient's fear and can lead to increased distress. Choice B might be an option, but it doesn't address the patient's anxiety in the moment. Choice C, while helpful in some cases, doesn't directly address the patient's specific fear of the blood draw procedure.
The family members are excited about being transferring t heir loved one from the critical care unit to the intermediate care unit. However, they are also fearful of the change in environment and nursing staff. To reduce relocation stress, the nurse ca n implement what intervention? (Select all that apply.)
- A. Arranging for the nurses on the intermediate care unit to give the family a tour of the new unit.
- B. Contacting the primary care provider to see if the patient can stay one additional day in the critical care unit so that the family can adjus t better to the idea of a transfer.
- C. Ensuring that the patient will be located near the nurse ’s station in the new unit.
- D. Inviting the nurse who will be assuming the patient’s care to meet with the patient and family in the critical care unit prior to transfer.
Correct Answer: A
Rationale: The correct answer is A (Arranging for the nurses on the intermediate care unit to give the family a tour of the new unit) because it helps familiarize the family with the new environment, alleviating their fears. The tour allows them to see where their loved one will be cared for, meet the nursing staff, and ask any questions they may have. This intervention promotes a smooth transition, reduces anxiety, and builds trust.
Choice B is incorrect because delaying the transfer doesn't address the fear of change and can prolong stress. Choice C is incorrect as proximity to the nurse's station may not necessarily reduce relocation stress for the family. Choice D is incorrect because meeting the new nurse in the current unit may not provide the same level of comfort and preparation compared to physically visiting the new unit.
Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply.)
- A. Hypotension
- B. Dysrhythmias
- C. Muscle cramps
- D. Hemolysis
Correct Answer: A
Rationale: The correct answer is A, hypotension. During hemodialysis for acute kidney injury, fluid removal can lead to hypotension due to rapid changes in blood volume. This can cause dizziness, weakness, and even loss of consciousness. Dysrhythmias (choice B) are less common but can occur due to electrolyte imbalances. Muscle cramps (choice C) may occur during or after dialysis due to electrolyte imbalances or fluid shifts, but they are not as common as hypotension. Hemolysis (choice D) is not a common complication of hemodialysis for acute kidney injury, as it is more commonly associated with issues related to the dialysis machine or blood tubing.