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What is true regarding pain and anxiety in the healthy individual? (Select all that apply.)
- A. They activate the sympathetic nervous system.
- B. They decrease stress levels.
- C. They help remove one from harm.
- D. They increase performance levels.
Correct Answer: A
Rationale: The correct answer is A because pain and anxiety trigger the sympathetic nervous system's fight-or-flight response, increasing heart rate, blood pressure, and stress hormones to prepare the body for potential danger. This physiological response helps the individual respond to perceived threats. Choices B, C, and D are incorrect because pain and anxiety typically increase stress levels, do not necessarily remove one from harm, and can hinder rather than enhance performance due to distraction and decreased focus.
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The nurse is caring for a terminally ill patient who has chosen palliative care. Which goal should the nurse prioritize when planning care?
- A. Cure the patient’s underlying disease.
- B. Manage the patient’s pain and symptoms.
- C. Prolong the patient’s life expectancy.
- D. Address the family’s concerns and questions.
Correct Answer: B
Rationale: The correct answer is B: Manage the patient's pain and symptoms. In palliative care, the primary goal is to provide comfort and improve quality of life for terminally ill patients. Managing pain and symptoms is crucial in achieving this goal. By addressing pain and symptoms, the nurse can help enhance the patient's comfort and well-being. Other choices are incorrect because palliative care focuses on improving quality of life rather than curing the underlying disease (A), prolonging life expectancy (C), or primarily addressing family concerns (D). Prioritizing pain and symptom management aligns with the holistic approach of palliative care.
When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient’s temperature is 101.8°F. What should the nurse plan to do next?
- A. Give analgesics and antibiotics as ordered.
- B. Discontinue the catheter and culture the tip.
- C. Change the flush system and monitor the site.
- D. Check the site more frequently for any swelling.
Correct Answer: B
Rationale: The correct answer is B: Discontinue the catheter and culture the tip. The patient's symptoms indicate a possible catheter-related infection. Discontinuing the catheter will prevent further infection spread. Culturing the tip will identify the specific pathogen causing the infection, guiding appropriate antibiotic therapy. Choice A is incorrect because giving analgesics alone will not address the underlying infection. Choice C is incorrect as changing the flush system is not a priority when infection is suspected. Choice D is incorrect as checking the site more frequently does not address the need for immediate action to address the infection.
A nurse in a burn unit observes that a patient is tensed up and frowning but silent. The nurse asks the patient, Can you tell me what you are thinking now? The patient responds, I cant take this pain any more! I feel like Im about to die. What would be the best response for the nurse to give to the patient, considering that the patient is already receiving the maximum amount pain medication that is safe?
- A. Try to get rid of those negative thoughtsthey only make it worse.
- B. Try thinking instead, This pain will go away; I can overcome it.
- C. Your pain medication is already at the highest possible dose.
- D. Would you like me to raise the head of your bed?
Correct Answer: C
Rationale: The correct response is C: Your pain medication is already at the highest possible dose. This response acknowledges the patient's pain and reassures them that they are already receiving the maximum safe amount of pain medication. By stating this, the nurse is validating the patient's experience and showing empathy. It is important for the nurse to communicate clearly about the medication to manage the patient's expectations.
Choice A is incorrect as it dismisses the patient's pain and can come across as insensitive. Choice B may be well-intentioned but does not address the immediate concern of the patient's pain. Choice D is irrelevant to the patient's statement about pain and does not offer any immediate support or reassurance regarding the pain management.
The nurse is caring for a patient who is orally intubated and on a mechanical ventilator. The nurse believes that the patient is experiencing excess anxiety. For this patient, what behavior best indicates anxiety?
- A. Restlessness
- B. Verbalization
- C. Increased respiratory rate
- D. Glasgow Coma Scale score of 3
Correct Answer: A
Rationale: The correct answer is A: Restlessness. Restlessness is a common behavioral indicator of anxiety in patients. In this scenario, a patient who is orally intubated and on a ventilator may not be able to verbally express anxiety, making restlessness a more prominent sign. Verbalization may not be possible due to intubation. While increased respiratory rate can be a symptom of anxiety, it is also a common physiological response in patients on mechanical ventilation. A Glasgow Coma Scale score of 3 indicates severe impairment of consciousness, not specifically anxiety.
Which intervention about visitation in the critical care unit is true?
- A. The majority of critical care nurses implement restricte d visiting hours to allow the patient to rest.
- B. Children should never be permitted to visit a critically ill family member.
- C. Visitation that is individualized to the needs of patients and family members is ideal.
- D. Visiting hours should always be unrestricted.
Correct Answer: C
Rationale: The correct answer is C because individualized visitation meets the unique needs of patients and family members, promoting holistic care and emotional support. Choice A is incorrect as strictly restricted visiting hours may hinder family involvement in care. Choice B is incorrect as children can provide comfort and support. Choice D is incorrect as unrestricted visiting may disrupt patient rest and care routines.