Nokea
A critically ill patient who is intubated and agitated is restrained with soft wrist restraints. Based on research findings, what is the best nursing action?
- A. Maintain the restraints to protect patient safety.
- B. Remove the restraints periodically to check skin integrity.
- C. Remove the restraints periodically for range of motion.
- D. Assess and intervene for causes of agitation. Answer Key
Correct Answer: D
Rationale: The correct answer is D: Assess and intervene for causes of agitation. In a critically ill patient, agitation while intubated could indicate underlying issues like pain, delirium, or inadequate sedation. By assessing and addressing the root cause of agitation, the nurse can improve patient comfort and prevent potential harm from restraints. Removing restraints periodically for skin integrity (B) and range of motion (C) is important but should not be the primary focus when agitation is present. Maintaining restraints (A) without addressing the agitation could lead to increased distress and potential complications.
You may also like to solve these questions
The nurse wishes to increase the use of evidence-based practice in the critical care unit where he works. What is a significant barrier to the implementation of evidence-based practice?
- A. Use of computerized records by the hospital
- B. Health Information Privacy and Portability Act (HIPPA)
- C. Lack of knowledge about literature searches
- D. Strong collaborative relationships in the work setting
Correct Answer: C
Rationale: Rationale:
The correct answer is C because lack of knowledge about literature searches hinders the ability to find and utilize evidence-based practice guidelines. Nurses need to be skilled in conducting literature searches to access relevant research. Choices A, B, and D are incorrect as they do not directly impede the implementation of evidence-based practice in the critical care unit.
A nurse who works in an intermediate care unit has experienced high nursing turnover. The nurse manager is often considered to be an autocratic leade r by staff members and that leadership style is contributing to turnover. The nurse asks to be involved in developing new guidelines to prevent pressure ulcers in the patient populat ion. The nurse manager suggests that the nurse has not yet had enough experience to be on tahbierb p.croemv/teenstt ion task force. This situation and setting is an example of what form of ineffec tive leadership?
- A. Creating a barrier to inter-staff communication.
- B. Supporting a work environment that is unhealthy.
- C. Displaying ineffective decision making.
- D. Demonstrating nursing practice that is not evidence-based.
Correct Answer: C
Rationale: The correct answer is C: Displaying ineffective decision making. In this scenario, the nurse manager's decision to exclude the nurse from participating in developing new guidelines is an example of ineffective decision making. By dismissing the nurse's request based on lack of experience rather than considering their input and involvement, the manager is not utilizing the nurse's expertise and potentially missing out on valuable insights. This decision reflects a lack of inclusivity, collaboration, and respect for the nurse's professional growth and potential contributions. The other choices are not directly applicable in this context as the core issue lies in the manager's decision-making process.
The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include whic h intervention?
- A. Antiseptic oral care
- B. Bed rest with head of bed elevated
- C. Coughing and deep breathing
- D. Mobility
Correct Answer: D
Rationale: The correct answer is D: Mobility. Maintaining mobility helps prevent blood stasis, a leading factor in the development of pulmonary embolism. Movement promotes circulation, reducing the risk of blood clots.
A: Antiseptic oral care is important for oral hygiene but not directly related to preventing pulmonary embolism.
B: Bed rest with head of bed elevated can actually increase the risk of clots due to immobility.
C: Coughing and deep breathing are beneficial for preventing respiratory complications but do not address the underlying cause of pulmonary embolism.
Anxiety differs from pain in that way? (Select all that app ly.)
- A. Anxiety is confined to neurological processes in the brain.
- B. Anxiety is linked to reward and punishment centers in the limbic system.
- C. Anxiety is subjective; pain is not.
- D. Anxiety produces no actual tissue injury.
Correct Answer: B
Rationale: The correct answer is B because anxiety is indeed linked to reward and punishment centers in the limbic system, specifically involving the amygdala and prefrontal cortex. This connection influences emotional responses and behaviors related to anxiety. Choices A, C, and D are incorrect because anxiety involves both neurological and psychological processes beyond the brain, is highly subjective like pain, and can lead to physical symptoms without actual tissue injury.
Which interventions can the nurse use to facilitate communication with patients and families who are in the process of making decisions regarding end- of-life care options? (Select all that apply.)
- A. Communication of uniform messages from all healthca re team members
- B. An integrated plan of care that is developed collaborat ively by the patient, family, and healthcare team
- C. Facilitation of continuity of care through accurate shift -to-shift and transfer reports
- D. Limitation of time for families to express feelings in order to control family grief
Correct Answer: A
Rationale: The correct answer is A: Communication of uniform messages from all healthcare team members. This intervention is crucial to ensure consistency in information provided to patients and families, reducing confusion and enhancing trust. When all team members convey the same messages, it helps in clarifying options and facilitating decision-making.
Choices B and C are incorrect as they focus on care planning and continuity, which are important but not specifically related to facilitating communication in end-of-life care decisions. Choice D is incorrect as it suggests limiting time for families to express feelings, which can hinder effective communication and support during such a sensitive time.