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The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
- A. A nystagmus on the left.
- B. Exophthalmos on the right.
- C. Ptosis on the left eyelid.
- D. Astigmatism on the right.
Correct Answer: C
Rationale: The correct answer is C: Ptosis on the left eyelid. Ptosis refers to drooping of the eyelid, which is a common condition in older adults. In this scenario, the nurse should document the finding as ptosis on the left eyelid because the client's left upper eyelid is drooping, covering more of the iris than the right eyelid.
Explanation: Nystagmus (A) is an involuntary eye movement, not related to eyelid drooping. Exophthalmos (B) is the protrusion of the eyeball and not relevant to this scenario. Astigmatism (D) refers to a refractive error of the eye and does not cause eyelid drooping. Therefore, the correct choice is C as it accurately describes the client's condition.
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A patient on mechanical ventilation is experiencing severe agitation due to being on the ventilator. Which nursing intervention would be best?
- A. Performing breathing exercises with the patient
- B. Offering the patient a patient-controlled analgesic device
- C. Asking the physician to prescribe an antianxiety medication
- D. Offering the patient the patients own MP3 player to listen to
Correct Answer: B
Rationale: The correct answer is B: Offering the patient a patient-controlled analgesic device. This intervention allows the patient to self-administer pain relief, which can help alleviate discomfort associated with mechanical ventilation and reduce agitation. Breathing exercises (choice A) may not address the root cause of agitation. Asking for antianxiety medication (choice C) may not be immediate or ideal due to potential side effects. Offering an MP3 player (choice D) may provide distraction but may not effectively address the agitation caused by the ventilator.
Which of the following statements about comfort care is aacbcirubr.caotme/?te st
- A. Withholding and withdrawing life-sustaining treatment are distinctly different in the eyes of the legal community.
- B. Each procedure should be evaluated for its effect on the patient’s comfort before being implemented.
- C. Only the patient can determine what constitutes comfo rt care for him or her.
- D. Withdrawing life-sustaining treatments is considered e uthanasia in most states.
Correct Answer: C
Rationale: Step 1: Comfort care is focused on providing relief from suffering and improving quality of life.
Step 2: Patient-centered care emphasizes the individual's preferences and values.
Step 3: Patient autonomy is a fundamental principle in healthcare decision-making.
Step 4: Patients have the right to determine what constitutes comfort care for themselves.
Step 5: Therefore, statement C is correct as it aligns with the patient's autonomy and individualized care approach.
Summary:
- Choice A is incorrect because legal distinctions between withholding and withdrawing treatment may vary.
- Choice B is incorrect as it focuses on evaluating procedures rather than the patient's preferences.
- Choice D is incorrect as withdrawing life-sustaining treatments is not universally considered euthanasia.
What were the findings of the Study to Understand Progno ses and Preferences for Outcomes and Risks of Treatment (SUPPORT)?
- A. Clear communication is typical in the relationships bet ween most patients and healthcare providers.
- B. Critical care units often meet the needs of dying patients and their families.
- C. Disparities exist between patients’ care preferences anadb iarbc.tcuomal/t ecsat re provided.
- D. Pain and suffering of patients at end of life is well cont rolled in the hospital.
Correct Answer: C
Rationale: The correct answer is C because the SUPPORT study revealed disparities between patients' care preferences and the actual care provided. This is supported by the findings that many patients did not receive treatments aligned with their preferences. Choice A is incorrect because the study actually highlighted communication challenges between patients and healthcare providers. Choice B is incorrect as the study showed that critical care units often do not meet the needs of dying patients and their families. Choice D is incorrect as the study found that pain and suffering of patients at the end of life are not always well controlled in hospitals.
The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?
- A. Give intravenous (IV) calcium gluconate.
- B. Withhold the drug and notify the healthcare provider.
- C. Administer the dose as prescribed.
- D. Recheck the vital signs in 30 minutes and then administer the dose.
Correct Answer: C
Rationale: The correct answer is C: Administer the dose as prescribed. Verapamil is a calcium channel blocker used to treat atrial flutter. The vital signs obtained are within normal range for this medication. A heart rate of 92 and blood pressure of 110/76 are not contraindications for administering verapamil. Option A is incorrect as calcium gluconate is not indicated in this situation. Option B is incorrect because the vital signs are stable and do not warrant withholding the medication. Option D is incorrect as there is no need to delay the administration of verapamil based on the vital signs provided.
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.