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The patient is undergoing a necessary but painful procedure that is greatly increasing her anxiety. The nurse decides to use guided imagery to help alleviate the patients anxiety. What is a key part of this technique?
- A. Provide the patient with an external focus point such as a picture.
- B. Have the patient take slow, shallow breaths while staring at a focus point.
- C. Have the patient remember tactile sensations of a pleasant experience.
- D. Encourage the patient to consciously relax all of her muscles.
Correct Answer: C
Rationale: The correct answer is C because guided imagery involves using the patient's imagination to focus on pleasant sensory experiences. This helps distract the patient from the current situation and reduces anxiety. By remembering tactile sensations of a pleasant experience, the patient can create a calming mental image.
Choice A is incorrect because guided imagery does not require an external focus point like a picture. Choice B is incorrect because the technique does not involve staring at a focus point but rather focusing on mental images. Choice D is incorrect because while relaxation is beneficial, guided imagery specifically focuses on visualization of positive experiences to reduce anxiety.
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A nurse wishes to practice using the Synergy Model developed by the American Association of Critical-Care Nurses (AACN). What nursing behavior best supports use of this model?
- A. Attending mandatory hospital-wide in-service programs
- B. Self-directed study of best practice for the patients she cares for
- C. Gathering demographic data on the patients admitted to the unit
- D. Participating in a research study as a data collector
Correct Answer: B
Rationale: The correct answer is B: Self-directed study of best practice for the patients she cares for. This choice aligns with the Synergy Model by promoting individualized patient care based on best practices. Self-directed study allows the nurse to enhance their knowledge and skills to provide optimal care tailored to each patient's unique needs. Attending mandatory in-service programs (A) may not directly support the individualized care approach. Gathering demographic data (C) is important but not specific to the Synergy Model's focus on patient acuity and nurse competencies. Participating in a research study (D) may contribute to evidence-based practice, but it does not directly relate to the Synergy Model's emphasis on aligning nurse competencies with patient needs.
Both the electroencephalogram (EEG) monitor and the Bis pectral Index Score (BIS) or Patient State Index (PSI) analyzer monitors are used to ass ess patient sedation levels in critically ill patients. Why are the BIS and PSI monitors simpler to use?
- A. They are only be used on heavily sedated patients.
- B. They can only be used on pediatric patients.
- C. They provide raw EEG data and a numeric value.
- D. They require only five leads.
Correct Answer: C
Rationale: The correct answer is C because BIS and PSI monitors provide both raw EEG data and a numeric value, simplifying the interpretation of patient sedation levels. Raw EEG data offers detailed information on brain activity, while the numeric value allows for quick assessment. This simplifies the monitoring process compared to interpreting raw EEG data alone.
Choice A is incorrect as BIS and PSI monitors are not restricted to heavily sedated patients. Choice B is incorrect as they are not limited to pediatric patients. Choice D is incorrect as the number of leads required does not determine the simplicity of use; it is the data interpretation that matters.
The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that diagnosis include: (Select all that apply.)
- A. bladder catheterization.
- B. increasing fluid volume intake.
- C. ureteral stenting.
- D. placement of nephrostomy tubes.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Bladder catheterization helps relieve urinary obstruction, a common postrenal cause of acute kidney injury.
2. By draining urine from the bladder, it prevents further damage to the kidneys.
3. This intervention addresses the underlying cause of the kidney injury, leading to improvement.
Summary:
- Choice A is correct as it directly addresses the postrenal cause by relieving urinary obstruction.
- Choices B, C, and D are incorrect as they do not target the specific postrenal cause of acute kidney injury.
The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient’s noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse?
- A. Activate the rapid response system.
- B. Place the patient in Trendelenburg position.
- C. Assess the cuff for proper arm size.
- D. Administer 0.9% normal saline bolus.
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Assess the cuff for proper arm size):
1. The cuff blood pressure (70/40 mm Hg) is significantly lower than the arterial blood pressure (108/70 mm Hg).
2. Discrepancy suggests cuff size mismatch, leading to inaccurate readings.
3. Assessing cuff size ensures accurate blood pressure measurement.
4. Ensures appropriate interventions based on accurate readings.
Summary of Incorrect Choices:
A: Rapid response not warranted based solely on blood pressure discrepancy.
B: Trendelenburg position not indicated for cuff size issue.
D: Normal saline bolus not appropriate without accurate blood pressure measurement.
Critical illness often results in family conflicts. Which scenario is most likely to result in the greatest conflict?
- A. A 21-year-old college student of divorced parents hosp italized with multiple trauma. She resides with her mother. The parents are amicable with each other and have similar values. The father blames the daughter’s b oyfriend for causing the accident.
- B. A 36-year-old male admitted for a ruptured cerebral an eurysm. He has been living with his 34-year-old girlfriend for 8 years, and they have a 4-year-old daughter. He does not have written advance directives. His parents aarbriribv.ceo mfr/otemst out-of-state and are asked to make decisions about his health care. He h as not seen them in over a year.
- C. A 58-year-old male admitted for coronary artery bypas s surgery. He has been living with his same-sex partner for 20 years in a committed relationship. He has designated his sister, a registered nurse, as his healthca re proxy in a written advance directive.
- D. A 78-year-old female admitted with gastrointestinal blaebeirdbi.cnogm./ tHeset r hemoglobin is decreasing to a critical level. She is a Jehovah’s Witness and refuses the treatment of a blood transfusion. She is capable of making her ow n decisions and has a clearly written advance directive declining any transfu sions. Her son is upset with her and tells her she is “committing suicide.”
Correct Answer: D
Rationale: The correct answer is D because it involves a conflict between the patient's autonomy and her son's beliefs. The patient, a Jehovah's Witness, has clearly stated her refusal of a blood transfusion in her advance directive, which aligns with her religious beliefs. Her son's disagreement with her decision creates a significant ethical dilemma and conflict. This scenario highlights the clash between respecting the patient's autonomy and the son's concerns for her well-being.
Choice A is less likely to result in the greatest conflict as both parents have similar values and are amicable, with the conflict being directed towards the daughter's boyfriend.
Choice B involves a conflict between the patient's girlfriend and parents, but the patient's lack of advance directives and estranged relationship with his parents do not present as significant a conflict as in the correct answer.
Choice C involves a designated healthcare proxy and a committed relationship, which are less likely to result in a conflict as compared to the clash of beliefs and autonomy seen in Choice D.