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The VALUE mnemonic is a helpful strategy to enhance communication with family members of critically ill patients. Which of the following statements describes a VALUE strategy?
- A. View the family as guests on the unit.
- B. Acknowledge family emotions.
- C. Learn as much as you can about family structure and f unction.
- D. Use a trained interpreter if the family does not speak English.
Correct Answer: B
Rationale: The correct answer is B: Acknowledge family emotions. This is a key component of the VALUE strategy as it emphasizes empathy and understanding towards the emotions that family members may be experiencing during a difficult time. By acknowledging their emotions, healthcare providers can build trust and establish a supportive relationship with the family.
Choice A is incorrect because the VALUE strategy focuses on treating family members as integral members of the care team, not just as guests. Choice C is incorrect as learning about family structure and function is important but not specifically part of the VALUE strategy. Choice D is incorrect as using a trained interpreter is important for effective communication but is not specific to the VALUE mnemonic.
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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.
The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring th e patient from the stretcher to the bed. Prior to obtaining a cardiac output, which action is m ost important for the nurse to complete?
- A. Document a pulmonary artery catheter occlusion press ure.
- B. Zero reference the transducer system at the phlebostatic axis.
- C. Inflate the pulmonary artery catheter balloon with 1 m L air.
- D. Inject 10 mL of 0.9% normal saline into the proximal port.
Correct Answer: B
Rationale: The correct answer is B: Zero reference the transducer system at the phlebostatic axis. This is the most important action before obtaining a cardiac output because zero referencing ensures accurate pressure readings. The phlebostatic axis is the level of the atria when the patient is supine, and zeroing at this point minimizes errors in pressure measurements.
Choice A is incorrect because documenting a pulmonary artery catheter occlusion pressure is not the priority at this stage. Choice C is incorrect as inflating the balloon with air should be done after zero referencing. Choice D is incorrect as injecting normal saline into the port is not necessary before zero referencing.
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.
What factors are common to both pain and anxiety? (Select all that apply.)
- A. Cyclical exacerbation of one another
- B. Require good nursing assessment for proper treatment
- C. Response only to real phenomena
- D. Perception is majorly influence by previous experience
Correct Answer: A
Rationale: The correct answer is A: Cyclical exacerbation of one another. Pain and anxiety can intensify each other in a cyclical manner. Pain can trigger anxiety, making the pain feel worse, and anxiety can heighten pain perception. This relationship is well-documented in research and clinical practice.
Choice B is incorrect because although both pain and anxiety benefit from thorough nursing assessment, it is not a factor common to both conditions.
Choice C is incorrect as both pain and anxiety can be influenced by real and perceived phenomena, not solely real phenomena.
Choice D is incorrect because while previous experiences can impact pain and anxiety perception, it is not a factor common to both conditions.
The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?
- A. Use tweezers to remove any remaining ticks.
- B. Check the vital signs, including temperature.
- C. Give doxycycline (Vibramycin) 100 mg orally.
- D. Obtain information about recent outdoor activities.
Correct Answer: A
Rationale: The correct answer is A: Use tweezers to remove any remaining ticks. The first step is to remove the tick to prevent further transmission of any potential pathogens. This is crucial in preventing tick-borne illnesses. Checking vital signs (B) can be done after the tick is removed. Administering doxycycline (C) should be based on guidelines and individual factors. Obtaining information about recent outdoor activities (D) is important but not the immediate priority.