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The nurse is caring for a critically ill patient who can speak. The nurse notices that the patient is demonstrating behaviors indicative of anxiety but is silent. What nursing strategy would give the nurse the most information about the patients feelings?
- A. Explain procedures to the patient and family.
- B. Ask the patient to share his or her internal dialogue.
- C. Encourage the patient to nap before visiting hours.
- D. Ensure that the patient has adequate pain control.
Correct Answer: B
Rationale: The correct answer is B because asking the patient to share his or her internal dialogue can provide direct insight into the patient's thoughts and feelings, allowing the nurse to address specific anxieties. This approach promotes open communication and understanding. Choice A focuses on providing information but may not directly address the patient's feelings. Choice C is unrelated to addressing the patient's anxiety. Choice D addresses pain control, which is important but not directly related to exploring the patient's emotions. Therefore, option B is the most effective strategy for gaining insight into the patient's feelings in this scenario.
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The nurse is caring for a patient who has an intra-aortic balloon pump in place. Which action should be included in the plan of care?
- A. Position the patient supine at all times.
- B. Avoid the use of anticoagulant medications.
- C. Measure the patient’s urinary output every hour.
- D. Provide a massive range of motion for all extremities.
Correct Answer: C
Rationale: The correct answer is C: Measure the patient’s urinary output every hour. This is crucial because monitoring urinary output is essential in assessing the patient’s renal function and the effectiveness of the intra-aortic balloon pump in improving cardiac output. Hourly measurement helps in early detection of any changes that may indicate complications.
A: Positioning the patient supine at all times is not necessary and can lead to complications.
B: Avoiding the use of anticoagulant medications is not appropriate as they are often necessary to prevent clot formation around the balloon pump.
D: Providing a massive range of motion for all extremities is not recommended for a patient with an intra-aortic balloon pump as it can dislodge the device or cause harm.
A PaCO 2 of 48 mm Hg is associated with what outcome?
- A. Hyperventilation
- B. Hypoventilation
- C. Increased absorption of O
- D. Increased excretion of HCO
Correct Answer: B
Rationale: The correct answer is B: Hypoventilation. A PaCO2 of 48 mm Hg indicates an elevated level of carbon dioxide in the blood, which is typically seen in hypoventilation where the lungs are not effectively removing CO2. Hypoventilation leads to respiratory acidosis. Option A is incorrect because hyperventilation would decrease PaCO2 levels. Option C is incorrect as it does not directly relate to PaCO2 levels. Option D is incorrect as increased excretion of HCO3- would not directly affect PaCO2 levels.
The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?
- A. Grave's disease.
- B. Multiple sclerosis.
- C. Addison's disease.
- D. Cushing syndrome.
Correct Answer: A
Rationale: Step 1: Symptoms of weight loss, racing heart rate, and difficulty sleeping are common in hyperthyroidism.
Step 2: Presence of moist skin, fine hair, prominent eyes, lid retraction, and staring expression are classic signs of Grave's disease, a type of hyperthyroidism.
Step 3: Grave's disease is an autoimmune disorder where the thyroid gland is overactive, leading to excessive production of thyroid hormones.
Step 4: Excess thyroid hormones increase metabolic rate, causing weight loss, racing heart rate, and insomnia.
Step 5: Therefore, the findings described in the question are consistent with Grave's disease.
The nurse observes that an elderly woman, whose granddaughter has been admitted to theICU, is struggling to manage her two great-grandsons, who are toddlers, in the waiting room. What is the most likely explanation for the womans inability to manage the children in this situation?
- A. She is senile.
- B. She is in the exhaustion stage of the general adaptation syndrome to stress.
- C. She is assuming the role of caregiver in place of the patient, a role she is not used to.
- D. She has macular degeneration and cannot see well.
Correct Answer: B
Rationale: The correct answer is B: She is in the exhaustion stage of the general adaptation syndrome to stress.
Rationale:
1. In the exhaustion stage, the body's resources are depleted due to prolonged stress, leading to fatigue and reduced ability to cope.
2. The elderly woman is likely experiencing high levels of stress due to her granddaughter's critical condition.
3. Managing toddlers while dealing with the emotional distress of a loved one in the ICU can be overwhelming, causing exhaustion.
4. This explanation aligns with the symptoms of fatigue and difficulty managing the children observed by the nurse.
Summary:
A: Incorrect. Senility is a cognitive condition unrelated to the stress of the situation.
C: Incorrect. Assuming a caregiver role can be stressful, but it does not explain the observed exhaustion.
D: Incorrect. Macular degeneration affects vision, not the ability to manage stress and children.
The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows ventricular tachycardia. The patient does not have a “do not resuscitate” order written on the chart. What is the appropriate nursing action?
- A. Contact the attending physician immediately to determ ine if CPR should be initiated.
- B. Contact the family immediately to determine if they waabnirtb .CcoPmR/te stot be started.
- C. Give emergency medications but withhold intubation.
- D. Initiate CPR and call a code.
Correct Answer: D
Rationale: The correct answer is D: Initiate CPR and call a code. In this scenario, the patient is critically ill with ventricular tachycardia, a life-threatening arrhythmia. Since there is no "do not resuscitate" order, the appropriate nursing action is to initiate CPR immediately to attempt to restore the patient's cardiac function and circulation. Calling a code will ensure that a team of healthcare providers can respond promptly with necessary interventions. Options A and B involve unnecessary delays in potentially life-saving interventions. Option C is incorrect as withholding intubation can compromise the patient's airway and oxygenation. Thus, option D is the most appropriate action to prioritize the patient's safety and well-being in this critical situation.