Nokea
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.
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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.
A patient has just been admitted to the ICU after being in a severe auto accident and losing one of her legs. Her husband has his hand over his heart and complains of a rapid heart rate. The nurse recognizes his condition as a sign of which stage of the general adaptation syndrome to stress?
- A. Alarm stage
- B. Exhaustion stage
- C. Resistance stage
- D. Adaptation stage
Correct Answer: A
Rationale: The correct answer is A: Alarm stage. The husband's rapid heart rate indicates the initial alarm reaction to stress, characterized by physiological arousal. This stage involves the body's fight-or-flight response to a stressor. In this scenario, the husband is experiencing the physiological effects of the stressful situation, such as the auto accident and loss of a limb. The other choices are incorrect because:
B: Exhaustion stage occurs if stress continues without relief, leading to depletion of resources and increased vulnerability to illness.
C: Resistance stage is the body's attempt to adapt and cope with the stressor after the initial alarm reaction.
D: Adaptation stage is not a recognized stage in the general adaptation syndrome model.
The sister of a patient in the ICU has been at the patients bedside non-stop for 48 hours. The nurse suggests to her that she return home to rest. Which of the following is the proper rationale for the nurse making such a suggestion?
- A. The sister is in the way of the health care providers.
- B. The patient may become annoyed by her continual presence.
- C. The patient will recover more easily in peace and quiet.
- D. The sister needs to maintain her own health during this time.
Correct Answer: D
Rationale: The correct answer is D: The sister needs to maintain her own health during this time. It is essential for the sister to take care of her own health and well-being to be able to provide the best support to the patient. Continuous stress and lack of rest can negatively impact her ability to support the patient effectively. Encouraging her to rest will ensure she remains physically and mentally well to continue supporting the patient in the long run.
Incorrect Choices:
A: The sister is in the way of the health care providers - This is incorrect as the primary concern is the well-being of the sister and her ability to provide support.
B: The patient may become annoyed by her continual presence - This is not the main reason for suggesting the sister to rest, as the focus is on her own health.
C: The patient will recover more easily in peace and quiet - While peace and quiet can be beneficial for the patient, the main focus here is on the sister's well-being.
A patient is having difficulty weaning from mechanical ve ntilation. The nurse assesses the patient and notes what potential cause of this difficult weaning?
- A. Cardiac output of 6 L/min
- B. Hemoglobin of 8 g/dL
- C. Negative sputum culture and sensitivity
- D. White blood cell count of 8000
Correct Answer: B
Rationale: The correct answer is B: Hemoglobin of 8 g/dL. Low hemoglobin levels can lead to inadequate oxygen delivery to tissues, causing respiratory distress and difficulty weaning from mechanical ventilation. This is due to reduced oxygen-carrying capacity leading to increased work of breathing.
A: Cardiac output of 6 L/min is within normal range and not directly related to difficulty weaning from mechanical ventilation.
C: Negative sputum culture and sensitivity indicate absence of respiratory infection but not a direct cause of difficulty weaning.
D: White blood cell count of 8000 is within normal range and not a direct cause of difficulty weaning.
The nurse is caring for a very seriously ill patient in the CCU. The family visits sporadically, stays for only a short time, and does not ask many questions. How could the nurse best begin to involve the family in the patients care?
- A. Ask one family member to assist with the patients bath.
- B. Encourage family members to stay longer at each visit.
- C. Focus nursing efforts on the patients legal next of kin.
- D. Ask the family to complete the Critical Care Family Needs Inventory.
Correct Answer: D
Rationale: The correct answer is D: Ask the family to complete the Critical Care Family Needs Inventory. This tool helps assess the family's needs and concerns, enabling the nurse to tailor care accordingly. By understanding the family's specific needs, the nurse can provide appropriate support and information, fostering better involvement and understanding.
A: Asking one family member to assist with the patient's bath may not address the overall family's needs or involvement in care.
B: Encouraging family members to stay longer does not necessarily address their specific needs or facilitate effective communication.
C: Focusing solely on the legal next of kin may exclude important family members who also need support and involvement in the patient's care.