Nokea
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.
You may also like to solve these questions
A client has been admitted after experiencing multiple trauma and is intubated and sedated. When the five members of the immediate family arrive, they are anxious, angry, and very demanding. They all speak loudly at once and ask for many services and answers. What is the best nursing response?
- A. Ask the family to leave until visiting hours begin.
- B. Take them to a private area for initial explanations.
- C. Page security to have them removed from unit.
- D. Show them to the clients bedside and leave them alone.
Correct Answer: B
Rationale: The correct answer is B: Take them to a private area for initial explanations. This response is the best because it allows the nurse to address the family's concerns in a private and controlled environment. It promotes effective communication and enables the family to express their emotions and receive information without distractions.
Choice A is incorrect because asking the family to leave may escalate the situation and not address their needs. Choice C is inappropriate as paging security to remove the family can worsen the family's distress and hinder communication. Choice D is not ideal as leaving the family alone may lead to misunderstandings and increased anxiety. Overall, choice B is the most therapeutic and effective approach in this situation.
The nurse is preparing to provide postmortem care for a patient who has just died. Which action should the nurse take first?
- A. Close the patient’s eyes and place a pillow under the head.
- B. Wash the patient’s body and apply a clean gown.
- C. Remove all medical equipment and tubes.
- D. Confirm that a death certificate has been signed.
Correct Answer: A
Rationale: Rationale:
A: Closing the patient's eyes and placing a pillow under the head is the first step in postmortem care to maintain dignity and prevent airway occlusion.
B: Washing the body and changing clothes can be done later and is not the priority.
C: Removing medical equipment can wait until after ensuring the patient's comfort.
D: Confirming the death certificate is important but not the immediate first step in postmortem care.
A patient presents to the emergency department in acute re spiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation?
- A. Emergency tracheostomy and mechanical ventilation
- B. Mechanical ventilation via an endotracheal tube
- C. Noninvasive positive-pressure ventilation (NPPV)
- D. Oxygen at 100% via bag-valve-mask device
Correct Answer: B
Rationale: The correct answer is B: Mechanical ventilation via an endotracheal tube. In acute respiratory failure, especially in the setting of pneumonia and COPD, mechanical ventilation is often necessary to support breathing. Endotracheal intubation allows for precise control of airway patency, oxygenation, and ventilation. Emergency tracheostomy (choice A) is typically reserved for long-term ventilatory support. Noninvasive positive-pressure ventilation (choice C) may not provide sufficient support in severe cases. Oxygen via bag-valve-mask (choice D) may not be adequate for ventilatory support in acute respiratory failure.
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.
What is the most common cause of a pulmonary embolus?
- A. An amniotic fluid embolus.
- B. A deep vein thrombosis from lower extremities.
- C. A fat embolus from a long bone fracture.
- D. Vegetation that dislodges from an infected central venous catheter.
Correct Answer: B
Rationale: The correct answer is B: A deep vein thrombosis from lower extremities. Deep vein thrombosis (DVT) is the most common cause of a pulmonary embolus as a blood clot can dislodge from the veins, travel to the lungs, and block blood flow. An amniotic fluid embolus (Choice A) occurs during childbirth and is rare as a cause of pulmonary embolism. A fat embolus (Choice C) typically occurs after a long bone fracture and is more likely to cause issues in the lungs. Vegetation from an infected central venous catheter (Choice D) can cause septic pulmonary embolism, but it is not as common as DVT.