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The nurse understands that a patient being cared for in a critical care unit experiences anacute stress response. What nursing action best demonstrates understanding of the physiological parts of the initial stress response?
- A. Adequate pain control
- B. Intravenous sedation
- C. Treatment for elevated blood pressure
- D. Ignoring an elevated glucose level
Correct Answer: C
Rationale: The correct answer is C: Treatment for elevated blood pressure. In the initial stress response, the body releases adrenaline and cortisol, leading to increased heart rate and blood pressure. Treating elevated blood pressure is crucial to prevent complications like heart attack or stroke. Adequate pain control (A) and intravenous sedation (B) may help manage symptoms but do not directly address the physiological response to stress. Ignoring an elevated glucose level (D) is not recommended as stress can impact blood sugar levels. Treatment for elevated blood pressure directly targets the physiological response to stress, making it the best nursing action in this scenario.
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Which therapeutic interventions may be withdrawn or withabhirebl.dco mfr/otemst the terminally ill client? (Select all that apply.)
- A. Antibiotics
- B. Dialysis
- C. Nutrition
- D. Pain medications
Correct Answer: B
Rationale: The correct answer is B: Dialysis. In the context of terminally ill clients, withdrawing dialysis is appropriate as it can be burdensome without providing significant benefit towards the end of life. Dialysis does not cure terminal conditions and can prolong suffering unnecessarily.
Antibiotics (A) may be necessary for managing infections in terminally ill clients. Nutrition (C) is important for comfort and quality of life. Pain medications (D) are essential for managing pain and should not be withdrawn unless no longer beneficial or requested by the patient.
A 65-year-old patient with a history of metastatic lung car cinoma has been unresponsive to chemotherapy. The medical team has determined that ther e are no additional treatments available that will prolong life or improve the quality of lifaebi ribn.c oamn/yte smt eaningful way. Despite the poor prognosis, the patient continues to receive chemotherapy and full nutrition support. This is an example of what end-of-life concept?
- A. Medical futility
- B. Palliative care
- C. Terminal weaning
- D. Withdrawal of treatment
Correct Answer: A
Rationale: The correct answer is A: Medical futility. In this scenario, the patient's condition is terminal with no treatment options left. Continuing chemotherapy offers no benefit and may even harm the patient. Medical futility refers to interventions that are unlikely to achieve the desired outcome.
B: Palliative care focuses on improving quality of life for patients with serious illnesses, which is not being addressed in this case.
C: Terminal weaning involves gradually removing life-support measures, which is not happening here.
D: Withdrawal of treatment would be appropriate if the treatments were no longer beneficial, but the issue here is the continued provision of futile treatment.
A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped?
- A. The patient’s heart rate is 97 beats/min.
- B. The patient’s oxygen saturation is 93%.
- C. The patient’s respiratory rate is 32 breaths/min.
- D. The patient’s spontaneous tidal volume is 450 mL.
Correct Answer: C
Rationale: The correct answer is C because a respiratory rate of 32 breaths/min indicates increased work of breathing, which could be a sign of respiratory distress. In a patient being weaned from mechanical ventilation, an elevated respiratory rate suggests that the patient may not be able to sustain adequate ventilation on their own. This warrants stopping the weaning protocol to prevent respiratory failure.
Choice A is incorrect because a heart rate of 97 beats/min is within normal range for an adult. Choice B is incorrect because an oxygen saturation of 93% is acceptable for a patient with COPD. Choice D is incorrect because a tidal volume of 450 mL is adequate for a patient weaning from mechanical ventilation.
A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement?
- A. I will take salt tablets when I work outdoors in the summer.
- B. I should take acetaminophen (Tylenol) if I start to feel too warm.
- C. I should drink sports drinks when working outside in hot weather.
- D. I will move to a cool environment if I notice that I am feeling confused.
Correct Answer: C
Rationale: The correct answer is C: "I should drink sports drinks when working outside in hot weather." This statement is correct because hypotension and elevated temperature could indicate dehydration and electrolyte imbalance due to excessive sweating in hot weather. Drinking sports drinks can help replenish electrolytes lost through sweating and prevent dehydration.
Incorrect choices:
A: Taking salt tablets can lead to an imbalance in electrolytes and worsen the condition.
B: Acetaminophen can lower fever but does not address dehydration or electrolyte imbalance.
D: Moving to a cool environment when feeling confused is important but does not address the underlying issue of dehydration and electrolyte imbalance.
An elderly patient is admitted to the ICU with stage IV lung cancer, diabetes mellitus, and congestive heart failure. The health care team assembled to care for her is large and diverse, including an oncologist, a pulmonologist, an endocrinologist, a cardiologist, and others. The patient is not expected to survive more than a few weeks, and her husband is overwhelmed with stress and grief. Which nurse competency or competencies are most needed in this situation? Select all that apply.
- A. Clinical judgment
- B. Caring practices
- C. Collaboration
- D. Response to diversity
Correct Answer: B
Rationale: The correct answer is B: Caring practices. In this situation, the patient and her husband are dealing with complex medical conditions and emotional distress. Caring practices involve providing compassionate, empathetic, and supportive care to the patient and her family members during this difficult time. The nurse needs to show sensitivity, understanding, and emotional support to help them cope with their situation. Clinical judgment (A) is important but not the primary focus in this scenario. Collaboration (C) is essential in the interdisciplinary team, but caring practices take precedence in addressing the emotional needs. Response to diversity (D) is also important, but in this case, the focus is more on providing compassionate care rather than addressing cultural or social diversity issues.