Nokea
A critically ill patient tells the nurse that he is not afraid to die because he believes in reincarnation. What is the most appropriate nursing response?
- A. What if reincarnation is not real?
- B. This belief gives you strength.
- C. I dont believe in reincarnation.
- D. You shouldnt base your hopes on such a belief.
Correct Answer: B
Rationale: The correct answer is B because it acknowledges and validates the patient's belief, showing empathy and support. By stating that the belief gives strength, the nurse facilitates a therapeutic relationship and promotes the patient's emotional well-being. Choice A is incorrect as it challenges the patient's belief system, potentially creating conflict. Choice C is inappropriate as it dismisses the patient's belief and could damage the nurse-patient relationship. Choice D is also incorrect as it invalidates the patient's belief and could harm trust and rapport.
You may also like to solve these questions
The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the healthcare provider immediately if the patient develops:
- A. Oxygen saturation of 93%.
- B. Respirations of 20 breaths/minute.
- C. Green nasogastric tube drainage.
- D. Increased jugular venous distention.
Correct Answer: D
Rationale: The correct answer is D: Increased jugular venous distention. In a patient with a subarachnoid hemorrhage and on mechanical ventilation, increased jugular venous distention can indicate increased intracranial pressure, which can be life-threatening. The nurse should notify the healthcare provider immediately as it may require urgent intervention to prevent further neurological deterioration.
A: Oxygen saturation of 93% is within the acceptable range for a patient on mechanical ventilation and may not require immediate notification.
B: Respirations of 20 breaths/minute are within normal limits for a ventilated patient and do not necessarily indicate a critical condition.
C: Green nasogastric tube drainage may indicate the presence of bile and could be related to gastrointestinal issues, but it does not pose an immediate threat to the patient's neurological status.
The nurse is caring for a patient with severe neurological impairment following a massive stroke. The primary care provider has ordered tests to detearbmirbi.ncoem b/treasit n death. The nurse understands that criteria for brain death includes what crite ria? (Select all that apply.)
- A. Absence of cerebral blood flow.
- B. Absence of brainstem reflexes on neurological examin ation.
- C. Presents of Cheyne-Stokes respirations.
- D. Confirmation of a flat electroencephalogram.
Correct Answer: A
Rationale: The correct answer is A: Absence of cerebral blood flow. Brain death is determined by the irreversible cessation of all brain functions, including blood flow to the brain. When there is no cerebral blood flow, the brain is unable to function, leading to brain death. This criterion is essential in diagnosing brain death as it indicates a complete loss of brain function.
Explanation for why the other choices are incorrect:
- B: Absence of brainstem reflexes on neurological examination is a common sign of brain death, but it is not the primary criterion.
- C: Presence of Cheyne-Stokes respirations is not indicative of brain death. It is a pattern of breathing that can be seen in various conditions, not specifically brain death.
- D: Confirmation of a flat electroencephalogram is a supportive test for brain death but not the primary criterion. The absence of brain activity on an EEG can help confirm brain death but is not as definitive as the absence of cerebral blood flow.
The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis?
- A. Glasgow Coma Scale score of 3
- B. Train-of-four yields two twitches
- C. Bispectral index of 60
- D. CAM-ICU positive
Correct Answer: B
Rationale: The correct answer is B: Train-of-four yields two twitches. This assessment indicates a target level of paralysis because a train-of-four ratio of 2 twitches out of 4 suggests a 50% neuromuscular blockade, which is often the goal for patients receiving paralysis for procedures or ventilation.
A: A Glasgow Coma Scale score of 3 assesses consciousness, not neuromuscular blockade.
C: A Bispectral index of 60 measures depth of anesthesia, not paralysis level.
D: CAM-ICU assesses delirium, not neuromuscular blockade.
The nurse is a member of a committee to design a critical care unit in a new building. Which design trend would best be implemented to facilitate famil y-centered care?
- A. Ensuring that the patient’s room is large enough to inc lude a sleeper sofa and storage for family members’ personal belongings.
- B. Including a diagnostic suite in close proximity to the u nit so that the patient does not have to travel far for testing.
- C. Incorporating a large waiting room on the top floor of athbierb .hcooms/pteistta l with a scenic view and amenities such as coffee and tea.
- D. Providing access to a scenic garden for meditation.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Family-centered care promotes involvement of family members in patient care.
2. A sleeper sofa in the patient's room allows family members to stay overnight, enhancing support for the patient.
3. Storage for personal belongings ensures families can have essentials close by, increasing comfort and convenience.
4. These design elements facilitate family presence, communication, and participation in care, aligning with family-centered care principles.
Summary of Incorrect Choices:
B. Having a diagnostic suite nearby is convenient but not directly related to family-centered care principles.
C. A waiting room with amenities is beneficial but does not directly involve families in patient care.
D. Access to a garden for meditation is helpful for relaxation but does not emphasize family involvement in care.
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.