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The nurse is caring for four patients on the progressive car e unit. Which patient is at greatest risk for developing delirium?
- A. 36-year-old recovering from a motor vehicle crash with an alcohol withdrawal protocol.
- B. 54-year-old postoperative aortic aneurysm resection with an elevated creatinine level
- C. 86-year-old from nursing home, postoperative from coalboirnb .croemse/tecstti on
- D. 95-year-old with community-acquired pneumonia; fam ily has brought in eyeglasses and hearing aid
Correct Answer: C
Rationale: The correct answer is C, the 86-year-old postoperative from colonic resection. This patient is at the greatest risk for delirium due to being elderly, having undergone surgery, and having a history of being from a nursing home. These factors contribute to an increased susceptibility to delirium.
A: The 36-year-old with alcohol withdrawal may be at risk for delirium tremens, but the older age of the patient in choice C places them at higher risk.
B: The 54-year-old with an elevated creatinine level postoperative is at risk for complications, but age and history of nursing home placement increase the risk for delirium in choice C.
D: The 95-year-old with community-acquired pneumonia is at risk for delirium, but the combination of age, surgery, and nursing home history in choice C presents a greater risk.
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The son of a dying patient tells the nurse, 'Mother doesn’t respond anymore when I visit. I don’t think she knows that I am here.' Which response by the nurse is appropriate?
- A. You may need to cut back your visits, for now, to avoid overtiring your mother.
- B. Withdrawal may sometimes be a normal response when preparing to leave life.
- C. It will be important for you to stimulate your mother as she gets closer to dying.
- D. Many patients don’t know what is going on around them at the end of life.
Correct Answer: B
Rationale: The correct answer is B because withdrawal is a common psychological response in the dying process. The nurse should explain to the son that his mother's lack of response may be her way of preparing to leave life. This response validates the son's concerns while providing reassurance.
Choice A is incorrect because cutting back visits may not address the underlying issue of the mother's withdrawal. Choice C is incorrect because stimulating the mother may not be beneficial or appropriate in this situation. Choice D is incorrect because not all patients experience a lack of awareness at the end of life, and assuming so may not be helpful in this context.
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.
The nurse is caring for a mechanically ventilated patient. T he primary care providers are considering performing a tracheostomy because the patienatb iirsb .hcoamv/itensgt difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following?
- A. Patient outcomes are better if the tracheostomy is done within a week of intubation.
- B. Percutaneous tracheostomy can be done safely at the b edside by the respiratory therapist.
- C. Procedures performed in the operating room are associaabtirebd.c owmi/ttehs tf ewer complications.
- D. The greatest risk after a percutaneous tracheostomy is accidental decannulation.
Correct Answer: C
Rationale: The correct answer is C: Procedures performed in the operating room are associated with fewer complications. This is because performing a tracheostomy in the operating room allows for better control of the environment, equipment, and expertise of the surgical team. In this setting, the risk of complications such as bleeding, infection, and injury to surrounding structures is minimized.
Choices A, B, and D are incorrect:
A: Patient outcomes are better if the tracheostomy is done within a week of intubation - This statement is not universally true and depends on individual patient factors. Timing of tracheostomy should be based on the patient's clinical condition and not a set timeline.
B: Percutaneous tracheostomy can be done safely at the bedside by the respiratory therapist - While percutaneous tracheostomy can be performed at the bedside, it is typically done by a trained physician or surgeon due to the potential risks and complications involved.
D: The greatest risk after a per
A 75-year-old patient, who suffered a massive stroke 3 weeks ago, has been unresponsive and
- A. The primary health care provider has approached the spouse regarding placement of a perma nent feeding tube. The spouse states that the patient never wanted to be kept alive by tub es and personally didn’t want what was being done. After holding a family conference with th e spouse, the medical team concurs and the feeding tube is not placed. What term would be used to describe this situation?
- B. Euthanasia
- C. Palliative care
- D. Withdrawal of life support
Correct Answer: E
Rationale: Step 1: The scenario describes a decision made based on the patient's previously expressed wishes.
Step 2: The decision aligns with the principle of respecting patient autonomy.
Step 3: The term that best describes this situation is "Advance Directive."
Summary:
- A: Incorrect, as it involves actively ending the patient's life without their consent.
- B: Incorrect, as euthanasia involves intentionally causing death to relieve suffering.
- C: Incorrect, as palliative care focuses on improving quality of life for the patient.
- D: Incorrect, as withdrawal of life support involves discontinuing medical interventions, not honoring the patient's wishes.
What is the most important nursing intervention for patien ts who receive neuromuscular blocking agents?
- A. Administer sedatives in conjunction with the neuromu as bc iu rbl .a cor m b /tl eo sc t king agents.
- B. Assess neurological status every 30 minutes.
- C. Avoid interaction with the patient, because he or she won’t be able to hear.
- D. Restrain the patient to avoid self-extubation.
Correct Answer: B
Rationale: The correct answer is B: Assess neurological status every 30 minutes. This intervention is crucial for patients receiving neuromuscular blocking agents to monitor for any adverse effects such as respiratory depression or paralysis. Regular assessments help ensure early detection of complications and prompt intervention.
A: Administering sedatives in conjunction with neuromuscular blocking agents can potentiate respiratory depression and lead to respiratory compromise.
C: Avoiding interaction with the patient is not appropriate as communication and patient interaction are important aspects of nursing care.
D: Restraint should be avoided as it can increase the risk of complications such as pressure ulcers, anxiety, and decreased respiratory function.
Overall, regular neurological assessments are essential for ensuring patient safety and prompt intervention in case of any complications.