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A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care?
- A. One chronic and one acute illness.
- B. Two acute illnesses.
- C. One acute and one infectious illness.
- D. Two chronic illnesses.
Correct Answer: A
Rationale: The correct answer is A: One chronic and one acute illness. This is because Type 2 diabetes mellitus is a chronic condition, while influenza is an acute illness. The nurse should develop goals addressing the management and control of the chronic condition (diabetes) as well as the treatment and recovery from the acute illness (influenza). This approach ensures comprehensive care that considers both the long-term management of the chronic illness and the immediate needs related to the acute illness.
Choices B, C, and D are incorrect because they do not address the combination of chronic and acute illnesses presented in the scenario. Choice B focuses solely on two acute illnesses, which overlooks the ongoing management required for the chronic condition. Choice C combines an acute and an infectious illness, but fails to account for the chronic illness component. Choice D involves two chronic illnesses, neglecting the immediate care needed for the acute illness.
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Continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis in that
- A. a hemofilter is used to facilitate ultrafiltration.
- B. it provides faster removal of solute and water.
- C. it does not allow diffusion to occur.
- D. the process removes solutes and water slowly.
Correct Answer: D
Rationale: The correct answer is D because CRRT removes solutes and water slowly, which is beneficial for hemodynamically unstable patients. This slow removal allows for gradual fluid and electrolyte balance adjustments, reducing the risk of hemodynamic instability.
A: Incorrect - A hemofilter is indeed used in CRRT, but this choice does not highlight the key difference between CRRT and intermittent hemodialysis.
B: Incorrect - CRRT actually provides slower solute and water removal compared to intermittent hemodialysis.
C: Incorrect - Diffusion does occur in CRRT, as it is a key mechanism for solute removal in the process.
In summary, the key difference between CRRT and intermittent hemodialysis is the slow removal of solutes and water in CRRT, making choice D the correct answer.
A new nurse has recently joined the ICU from a different hospital, which had a much stricter policy regarding visiting hours. She expresses concern about the impact of open visiting hours on patient well-being. Which of the following would be the best explanation for the purpose of open visiting hours? Select all that apply.
- A. To better provide rest and quiet
- B. To strengthen the relationship between the family and health care provider
- C. To control the number of visitors for a patient
- D. To provide an undisturbed environment
Correct Answer: B
Rationale: The correct answer is B: To strengthen the relationship between the family and health care provider.
Rationale:
1. Open visiting hours encourage family involvement in care, fostering a partnership between healthcare providers and families.
2. Family support can positively impact patient outcomes and satisfaction.
3. It allows families to be updated on the patient's condition and involved in decision-making.
4. Strengthening the relationship can lead to better communication and trust between all parties.
Summary of Incorrect Choices:
A: Open visiting hours may disrupt rest and quiet, but the primary purpose is not to provide rest.
C: Open visiting hours do not aim to control the number of visitors but rather encourage family involvement.
D: While open visiting hours may not provide an entirely undisturbed environment, the focus is on improving family-provider relationships.
Which is likely the most common recollection from a patie nt who required endotracheal intubation and mechanical ventilation?
- A. Difficulty communicating
- B. Inability to get comfortable
- C. Pain
- D. Sleep disruption
Correct Answer: A
Rationale: The correct answer is A: Difficulty communicating. When a patient undergoes endotracheal intubation and mechanical ventilation, they are unable to speak normally. This leads to frustration and anxiety due to the inability to communicate effectively with healthcare providers and loved ones. The lack of communication can also impact their emotional well-being. Choices B, C, and D are less likely as the most common recollection because patients might not remember feeling uncomfortable, experiencing pain, or having sleep disruption during sedation and ventilation. Additionally, the inability to communicate is a primary concern for patients in this situation.
A 28-year-old patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take?
- A. Prepare to administer rabies immune globulin (BayRab).
- B. Assist the health care provider with suturing the bite wounds.
- C. Teach the patient the reason for the use of prophylactic antibiotics.
- D. Keep the wounds dry until the health care provider can assess them.
Correct Answer: C
Rationale: The correct answer is C: Teach the patient the reason for the use of prophylactic antibiotics. This is the most important action because human bites can introduce harmful bacteria into the wound, leading to infection. Prophylactic antibiotics help prevent infection in deep human bite wounds.
Choice A is incorrect because rabies immune globulin is not indicated for human bite wounds. Choice B is incorrect because suturing human bite wounds can trap bacteria and increase the risk of infection. Choice D is incorrect because keeping the wounds dry is not sufficient; proper wound cleaning and antibiotic treatment are essential in this case.
The nurse is caring for a patient with an admitting diagnosis of congestive failure. While attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse?
- A. Limit the patient’s supine position to no more than 10 seconds.
- B. Administer anxiety medications while recording the pressure.
- C. Encourage the patient to take slow deep breaths while asbuirpb.icnoem./ test
- D. Elevate the head of the bed 45 degrees while recording pressures.
Correct Answer: D
Rationale: The correct answer is D: Elevate the head of the bed 45 degrees while recording pressures.
Rationale:
1. Elevating the head of the bed will help improve the patient's breathing by reducing the pressure on the diaphragm.
2. This position will also help alleviate the patient's anxiety and tachypnea, promoting better oxygenation.
3. Recording pressures in this position will provide accurate data for monitoring the patient's condition.
Summary:
A: Limiting the supine position to 10 seconds does not address the underlying issues causing the patient's anxiety and tachypnea.
B: Administering anxiety medications without addressing the positioning issue may not effectively manage the patient's symptoms.
C: Encouraging the patient to take slow deep breaths is helpful, but changing the position of the patient is more crucial in this situation.