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What nursing strategies help families cope with the stress of critical illness? (Select all that apply.)
- A. Asking the family to leave during the morning bath to promote the patient’s privacy.
- B. Encouraging family members to make notes of questio ns they have for the physician during family rounds.
- C. When possible, providing continuity of nursing care.
- D. Providing a daily update of the patient’s condition to the family spokesperson.
Correct Answer: B
Rationale: The correct answer is B: Encouraging family members to make notes of questions they have for the physician during family rounds. This strategy helps families cope with the stress of critical illness by empowering them to stay informed and actively participate in the patient's care. By encouraging them to make notes, it promotes effective communication with the healthcare team and ensures that their concerns and questions are addressed promptly.
Other choices are incorrect:
A: Asking the family to leave during the morning bath to promote the patient’s privacy is not a helpful strategy for coping with stress as it may lead to feelings of isolation and lack of involvement in the patient's care.
C: Providing continuity of nursing care is important but may not directly address the family's coping mechanisms during a critical illness.
D: Providing a daily update of the patient’s condition to the family spokesperson is valuable but may not fully address the family's need for active participation and communication with the healthcare team.
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After a change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first?
- A. Patient who failed a spontaneous breathing trial and has been placed in rest mode on the ventilator.
- B. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring.
- C. Patient with central venous oxygen saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP).
- D. Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours.
Correct Answer: D
Rationale: The correct answer is D - Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours. This patient should be assessed first because the absence of urine output for 6 hours after being extubated could indicate acute kidney injury or other serious complications that need immediate attention. Urine output is a crucial indicator of renal function and can reflect the patient's overall hemodynamic status. In contrast, the other choices do not present immediate life-threatening conditions. Choice A involves a patient in rest mode post-failed breathing trial, which does not require immediate assessment. Choice B mentions continuous PETCO2 monitoring, which is important but not as urgent as assessing a patient with no urine output. Choice C describes a patient with a ScvO2 of 69%, which may need monitoring but does not indicate an urgent priority compared to assessing a patient with no urine output after recent extubation.
The nurse is assessing the patient’s pain using the Critical Care Pain Observation Tool (CPOT). Which of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention?
- A. Absence of vocal sounds
- B. Fighting the ventilator
- C. Moving legs in bed
- D. Relaxed muscles in upper extremities
Correct Answer: B
Rationale: The correct answer is B: Fighting the ventilator. This behavior indicates the patient is experiencing discomfort and struggling against the ventilator, suggesting a high likelihood of pain. The CPOT assesses pain through behaviors like grimacing, vocalization, and muscle tension, which are all present when a patient is fighting the ventilator. Absence of vocal sounds (Choice A) does not necessarily indicate pain as some patients may be silent even when in pain. Moving legs in bed (Choice C) could be due to restlessness rather than pain. Relaxed muscles in upper extremities (Choice D) do not reflect pain as the CPOT focuses on behaviors indicating discomfort.
Which of the following statements describes the core conc ept of the synergy model of practice?
- A. All nurses must be certified in order to have the synerg y model implemented.
- B. Family members must be included in daily interdisciplaibnirabr.cyo mro/teusnt ds.
- C. Nurses and physicians must work collaboratively and synergistically to influence care.
- D. Unique needs of patients and their families influence nursing competencies.
Correct Answer: D
Rationale: Rationale:
D is correct because the synergy model focuses on individualized care based on patients' unique needs. This model emphasizes tailoring nursing competencies to address these needs, promoting holistic care. A is incorrect as certification is not a requirement. B involves family inclusion but does not capture the core concept. C mentions collaboration but does not specifically address individualized care.
The nurse is caring for a mechanically ventilated patient b eing monitored with a left radial arterial line. During the inspiratory phase of ventilation, th e nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse?
- A. The mechanical ventilator is malfunctioning.
- B. The patient may require fluid resuscitation.
- C. The arterial line may need to be replaced.
- D. The left limb may have reduced perfusion.
Correct Answer: B
Rationale: The correct answer is B: The patient may require fluid resuscitation. A decrease in arterial blood pressure during the inspiratory phase of ventilation suggests decreased preload, indicating possible hypovolemia. This can be addressed by administering fluid resuscitation to improve cardiac output and blood pressure.
Incorrect Choices:
A: The mechanical ventilator is malfunctioning - There is no evidence to suggest a ventilator malfunction based on the arterial pressure change.
C: The arterial line may need to be replaced - The arterial line itself is unlikely to cause the observed pressure change.
D: The left limb may have reduced perfusion - This is less likely as the pressure change is likely systemic due to decreased preload.
The nurse is assigned to care for a patient who is a non-na tive English speaker. What is the best way to communicate with the patient and family to provide updates and explain procedures?
- A. Conduct a Google search on the computer to identify resources for the patient and family in their native language. Print these for their use .
- B. Contact the hospital’s interpreter service for someone to translate.
- C. Get in touch with one of the residents that you know is fluent in the native language and ask him if he can come up to the unit.
- D. Use a young family member who is fluent in both English and the native language to translate for you.
Correct Answer: B
Rationale: The correct answer is B: Contact the hospital’s interpreter service for someone to translate. This is the best option as it ensures accurate communication between the nurse, patient, and family. Hospital interpreters are trained professionals who can accurately convey medical information, ensuring understanding and informed decision-making. Using Google search (A) may result in inaccurate information and is not reliable for medical communication. Asking a resident (C) who is fluent may not guarantee accuracy in medical terminology. Using a young family member (D) as a translator can lead to miscommunication due to potential language barriers or lack of medical knowledge. Overall, option B is the most appropriate and ethical choice for effective communication in a healthcare setting.