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The patient’s spouse is very upset because the patient, who is near death, has dyspnea and restlessness. The nurse explains what options to decrease the discomfort?
- A. Respiratory therapy treatments
- B. Opioid medications given as needed
- C. Incentive spirometry treatments
- D. Increased hydration.
Correct Answer: B
Rationale: The correct answer is B: Opioid medications given as needed. Opioids are indicated for managing dyspnea and restlessness in palliative care by providing relief from symptoms. They act as potent analgesics and can help decrease the distress associated with difficult breathing and restlessness. Respiratory therapy treatments (A) and incentive spirometry treatments (C) may not address the immediate discomfort caused by dyspnea and restlessness. Increased hydration (D) may not directly alleviate the symptoms and could potentially worsen the patient's discomfort.
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A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care?
- A. Administer prescribed sedatives or opioids at bedtime to promote sleep.
- B. Cluster nursing activities so that the patient has uninterrupted rest periods.
- C. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps.
- D. Eliminate assessments between 0100 and 0600 to allow uninterrupted sleep.
Correct Answer: B
Rationale: The correct answer is B: Cluster nursing activities so that the patient has uninterrupted rest periods.
Rationale:
1. Clustering nursing activities allows for uninterrupted rest periods, essential for improving sleep quality and addressing disturbed sensory perception.
2. Administering sedatives or opioids (Option A) can lead to drug dependence, tolerance, and adverse effects in older adults.
3. Silencing alarms (Option C) compromises patient safety by impeding timely monitoring and response to critical events.
4. Eliminating assessments (Option D) between 0100 and 0600 disregards the necessity of monitoring vital signs and assessing patient condition around the clock.
The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle crash. The patient’s Glasgow Coma Score is 3 anda binirbte.cromm/ittetset ntly withdraws when painful stimuli are introduced. The patient is ventilator dependent and occasionally takes a spontaneous breath. The primary care provider explains to the family that the patient has severe neurological impairment and it is not expected that the patient will ever recover consciousness. What concept does this situation depict?
- A. An organ donor
- B. Brain death
- C. A persistent vegetative state
- D. Terminally ill
Correct Answer: C
Rationale: The correct answer is C: A persistent vegetative state. This choice is correct because the patient exhibits minimal responsiveness, only withdrawing to painful stimuli, and lacks meaningful interaction or consciousness. A persistent vegetative state is characterized by preserved wakefulness without awareness, which aligns with the patient's condition.
Choice A: An organ donor is incorrect because the patient's neurological impairment does not necessarily indicate readiness for organ donation.
Choice B: Brain death is incorrect because the patient still exhibits some reflexive responses, indicating a level of brain function beyond brain death.
Choice D: Terminally ill is incorrect as it does not specifically address the patient's neurological status and prognosis, which is better described by a persistent vegetative state.
What factors associated with the critical care unit can pred ispose the client to increased pain and anxiety? (Select all that apply.)
- A. Presence of an endotracheal tub
- B. Frequent vital sign assessment
- C. Monitor alarms
- D. Room temperature
Correct Answer: A
Rationale: The presence of an endotracheal tube can predispose the client to increased pain and anxiety due to discomfort, difficulty breathing, and potential for aspiration. The tube insertion process itself can be painful and traumatic. Frequent vital sign assessment, monitor alarms, and room temperature are not directly associated with increased pain and anxiety from the endotracheal tube.
Which statement is true regarding venous thromboembolisambir b(.VcoTm/Ete)s ta nd pulmonary embolus (PE)?
- A. PE should be suspected in any patient who has unexpla ined cardiorespiratory complaints and risk factors for VTE.
- B. Bradycardia and hyperventilation are classic symptom s of PE.
- C. Dyspnea, chest pain, and hemoptysis occur in nearly a ll patients with PE.
- D. Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis.
Correct Answer: A
Rationale: The correct answer is A because PE should be suspected in patients with unexplained cardiorespiratory complaints and risk factors for VTE. This is important because PE can present with nonspecific symptoms, making it crucial to consider it in the differential diagnosis.
Explanation:
1. PE can present with various symptoms, including dyspnea, chest pain, and hemoptysis, but these are not present in all patients.
2. Bradycardia and hyperventilation are not classic symptoms of PE, as it can present with tachycardia and other respiratory findings.
3. Critically ill patients are actually at higher risk for VTE and PE, so prophylaxis is typically recommended.
In summary, choice A is correct because it emphasizes the importance of considering PE in patients with cardiorespiratory complaints and risk factors for VTE, while the other choices contain inaccuracies or incomplete information.
A 15-year-old boy is in the ICU and preparing for an appendectomy. He is clearly anxious and fidgets with his IV constantly. He complains that he doesnt want to be there and he is sick of everyone telling him what to do. What would be the best way for the nurse to address this patients anxiety?
- A. Use physical restraints to keep him from pulling out his IV.
- B. Offer him the remote to the television.
- C. Lower the head of his bed so that he can rest more easily.
- D. Explain to the patient in detail what the appendectomy will consist of.
Correct Answer: B
Rationale: The correct answer is B: Offer him the remote to the television. This is the best way to address the patient's anxiety because it provides a distraction and a sense of control, which can help alleviate anxiety. By offering the patient the remote to the television, the nurse is giving him a choice and a way to focus his attention away from his anxiety. This can help him feel more comfortable and empowered in the situation.
Choice A is incorrect because using physical restraints can increase the patient's anxiety and sense of helplessness. Choice C, lowering the head of his bed, may provide physical comfort but does not directly address his anxiety. Choice D, explaining the procedure in detail, may further increase his anxiety as it focuses on the surgery rather than addressing his current emotional state.