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Many critically ill patients experience anxiety. The nurse can reduce anxiety with which approach?
- A. Asking family members to limit their visitation to 2-hour periods in morning, afternoon, and evening. You know that this is the best approach to ensure uninterrupted rest time for the patient. Tell the patient, “Your family is in the waiting room. They will be permitted to come in at 2:0 0 PM after you take a short nap.”
- B. Explaining the unit routine. “Assessments are done every 4 hours; patients are bathed on the night shift around 5:00 AM; family memabbierbr.sc oamr/ete spt ermitted to visit you after the physicians make their morning rounds. They can spend the day. Lights are out every night at 10:00 PM.”
- C. Stating, “It’s time to turn you. I am going to ask another nurse to come in and help me. We will turn you to your left side. During the turn , I’m going to inspect the skin on your back and rub some lotion on your back. T his should help to make you feel better.”
- D. Suctioning the endotracheal tube immediately when thaeb iprba.ctoiemn/tte sst tarts to cough. Sharing, “Your tube needs suctioned; you should feel better after I’m done.”
Correct Answer: C
Rationale: The correct answer is C because it addresses the patient's anxiety by providing clear communication and involving the patient in the care process. By explaining the turning procedure, inspecting the skin, and providing comfort through lotion application, the nurse establishes trust and promotes a sense of control for the patient. This approach helps alleviate anxiety by keeping the patient informed and engaged in their care.
Choice A is incorrect because limiting family visitation may not directly address the patient's anxiety. Choice B is incorrect as it focuses on routine information rather than directly addressing the patient's anxiety. Choice D is incorrect because suctioning the endotracheal tube may cause discomfort and does not address the underlying anxiety issue.
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What were identified as the first critical care units? (Select all that apply.)
- A. Burn units.
- B. Coronary care units
- C. Recovery rooms.
- D. Neonatal intensive care units.
Correct Answer: A
Rationale: The correct answer is A: Burn units. Burn units were identified as the first critical care units due to the complex and intensive care required by burn patients. These units were established to provide specialized care for burn victims, including wound management, infection control, and fluid resuscitation.
Summary:
- Burn units were the first critical care units due to the specialized care needed for burn patients.
- Coronary care units focus on cardiac conditions, not the first identified critical care units.
- Recovery rooms are for post-operative care, not specifically for critical care.
- Neonatal intensive care units are specialized for newborns, not the first critical care units.
A Muslim patient has been admitted to the critical care unit with complications after childbirth. Based on the Synergy Model, which nurse would be the most inappropriate to assign to care for this patient?
- A. New graduate female nurse
- B. Most experienced female nurse
- C. New graduate male nurse
- D. Female nurse with postpartum experience
Correct Answer: C
Rationale: Step-by-step rationale:
1. The Synergy Model emphasizes matching nurse competencies with patient needs.
2. A male nurse may not be culturally appropriate for a Muslim female patient due to religious beliefs.
3. Gender segregation is important in Islamic culture, especially concerning intimate care.
4. Therefore, assigning a new graduate male nurse to care for a Muslim female patient in critical condition is the most inappropriate choice.
Summary:
- Choice A is incorrect because being a new graduate does not impact cultural competence.
- Choice B is incorrect as experience does not necessarily make a nurse the best fit for a specific patient.
- Choice D is incorrect as postpartum experience is relevant, but cultural considerations are more critical in this scenario.
What factors may predispose a patient to respiratory acido as bi is rb? . com/test
- A. Anxiety and fear
- B. Central nervous system depression
- C. Diabetic ketoacidosis
- D. Nasogastric suctioning
Correct Answer: B
Rationale: The correct answer is B: Central nervous system depression. This factor can lead to respiratory acidosis by depressing the respiratory drive, causing hypoventilation and retention of carbon dioxide. Anxiety and fear (A) may lead to hyperventilation, reducing carbon dioxide levels. Diabetic ketoacidosis (C) results in metabolic acidosis, not respiratory acidosis. Nasogastric suctioning (D) may cause respiratory alkalosis from excessive removal of carbon dioxide. Thus, central nervous system depression is the most likely factor predisposing a patient to respiratory acidosis.
A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?
- A. Heart rate.
- B. Breath sounds.
- C. Body temperature.
- D. Level of consciousness.
Correct Answer: C
Rationale: The correct answer is C: Body temperature. In a patient who has fallen through the ice, hypothermia is a major concern due to exposure to cold water. Assessing body temperature first is crucial to determine the severity of hypothermia and guide immediate interventions. Heart rate, breath sounds, and level of consciousness can be affected by hypothermia but are secondary assessments. Assessing body temperature is the priority to address the most life-threatening issue first.
A nurse observes that a 38-year-old single father whose 11-year-old daughter is in the ICU is struggling to explain to his 6-year-old son the likelihood that the daughter will die. The young boy asks what will happen to his sister when she dies, but the father breaks down in tears and seems unable to respond. Which of the following would be the most appropriate intervention for the nurse to make?
- A. Suggest that the father contact his pastor, rabbi, or other spiritual leader for counself or him and his son
- B. Sit down with the father and son and share her own religious beliefs
- C. Ask the patients doctor to explain to the father the odds of the daughter surviving
- D. Leave the father and son to grieve alone
Correct Answer: A
Rationale: The correct answer is A. The nurse should suggest that the father contact his spiritual leader for counseling. This option is appropriate as it recognizes the importance of spirituality in coping with difficult situations. It offers emotional support and guidance to the father and his son during a time of crisis.
Option B is incorrect as the nurse sharing her own religious beliefs may not align with the father's beliefs, potentially causing confusion or discomfort.
Option C is not the best intervention, as the doctor's role is primarily medical, and explaining the odds of survival may not address the emotional and spiritual needs of the family.
Option D is also incorrect as leaving the father and son to grieve alone does not provide them with the necessary support and guidance during such a challenging time.