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When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most important information for the nurse to obtain is:
- A. Central venous pressure (CVP).
- B. Systemic vascular resistance (SVR).
- C. Pulmonary vascular resistance (PVR).
- D. Pulmonary artery wedge pressure (PAWP).
Correct Answer: D
Rationale: The correct answer is D: Pulmonary artery wedge pressure (PAWP). This is crucial in monitoring a patient with a large anterior wall myocardial infarction as it provides information on left ventricular function and fluid status. A high PAWP may indicate left ventricular failure or fluid overload, requiring immediate intervention.
A: Central venous pressure (CVP) is not as specific for assessing left ventricular function and may not provide accurate information in this scenario.
B: Systemic vascular resistance (SVR) is important in assessing systemic blood flow, but it may not directly indicate left ventricular function in this case.
C: Pulmonary vascular resistance (PVR) is more relevant in conditions affecting the pulmonary circulation and may not be as immediately informative in assessing left ventricular function in this context.
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The spouse of a patient with terminal cancer visits daily and cheerfully talks with the patient about wedding anniversary plans for the next year. When the nurse asks about any concerns, the spouse says, 'I’m busy at work, but otherwise, things are fine.' Which nursing diagnosis is most appropriate?
- A. Ineffective coping related to lack of grieving.
- B. Anxiety related to the complicated grieving process.
- C. Caregiver role strain related to feeling overwhelmed.
- D. Hopelessness related to knowledge deficit about cancer.
Correct Answer: A
Rationale: The correct answer is A: Ineffective coping related to lack of grieving. The spouse's behavior of avoiding the reality of the terminal illness and focusing on future plans indicates maladaptive coping. The cheerfulness and denial suggest a lack of acceptance and processing of the impending loss. This can lead to emotional distress and hinder the grieving process.
Choice B (Anxiety related to the complicated grieving process) is incorrect because the spouse's behavior does not exhibit signs of anxiety but rather avoidance and denial. Choice C (Caregiver role strain related to feeling overwhelmed) is incorrect as the spouse does not express feeling overwhelmed but instead deflects by focusing on work. Choice D (Hopelessness related to knowledge deficit about cancer) is incorrect because the spouse's behavior does not indicate hopelessness or lack of understanding about cancer, but rather an avoidance of facing the reality of the situation.
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.
The nurse caring for a mechanically ventilated patient prepares to include which strategies to prevent ventilator-associated pneumonia should be into the patient’s plan of care? (Select all that apply.)
- A. Drain condensate from the ventilator tubing away from the patient.
- B. Elevate the head of the bed 30 to 45 degrees.
- C. Instill normal saline as part of the suctioning procedure.
- D. Perform regular oral care with chlorhexidine.
Correct Answer: A
Rationale: The correct answer is A: Drain condensate from the ventilator tubing away from the patient. This is crucial to prevent ventilator-associated pneumonia as stagnant condensate can harbor harmful bacteria. By draining it away from the patient, the risk of bacterial growth and subsequent aspiration is minimized. Elevating the head of the bed (choice B) helps prevent aspiration but is not specific to preventing ventilator-associated pneumonia. Instilling normal saline during suctioning (choice C) can increase the risk of infection. Performing regular oral care with chlorhexidine (choice D) is important for oral hygiene but not directly related to preventing ventilator-associated pneumonia.
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 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.