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Which statement about family assessment is false?
- A. Assessment of structure (who comprises the family) is the last step in assessment.
- B. Interaction among family members is assessed.
- C. It is important to assess communication among family members to understand roles.
- D. Ongoing assessment is important, because family funcatbioirbn.cinomg/ tmesat y change during the course of illness.
Correct Answer: A
Rationale: The correct answer is A because assessing the structure of the family (who comprises the family) is not the last step in family assessment. The rationale is that understanding the family structure is essential at the beginning of the assessment process to identify key relationships and support systems. Assessing interaction among family members helps to understand dynamics and relationships within the family. Assessing communication is crucial to identify roles and patterns of interaction. Ongoing assessment is necessary as family dynamics can evolve throughout the illness. Therefore, A is false as family structure assessment is an important initial step, not the last step.
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An intra-aortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met?
- A. Urine output of 25 mL/hr.
- B. Heart rate of 110 beats/minute.
- C. Cardiac output (CO) of 5 L/min.
- D. Stroke volume (SV) of 40 mL/beat.
Correct Answer: C
Rationale: The correct answer is C: Cardiac output (CO) of 5 L/min. In cardiogenic shock, the primary goal of using an IABP is to improve cardiac output to ensure adequate perfusion to vital organs. A cardiac output of 5 L/min indicates adequate blood flow and perfusion.
Choice A is incorrect as urine output is not a direct indicator of cardiac function. Choice B is incorrect as a heart rate of 110 beats/minute alone does not provide information on the effectiveness of the IABP in improving cardiac output. Choice D is incorrect as stroke volume alone does not provide a comprehensive assessment of overall cardiac function.
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.
The most common cause of acute kidney injury in critically ill patients is
- A. sepsis.
- B. fluid overload.
- C. medications.
- D. hemodynamic instability.
Correct Answer: A
Rationale: The correct answer is A: sepsis. Sepsis is the most common cause of acute kidney injury in critically ill patients due to the systemic inflammatory response causing renal hypoperfusion. Sepsis leads to a decrease in renal blood flow, resulting in acute kidney injury. Fluid overload (B) can contribute to renal dysfunction but is not the primary cause in critically ill patients. Medications (C) can cause kidney injury, but sepsis is more prevalent. Hemodynamic instability (D) is a consequence of sepsis and can lead to acute kidney injury, making it an indirect cause.
The nurse is concerned about the risk of alcohol withdraw al syndrome in a 45-year-old postoperative patient. Which statement indicates an unders tanding of management of this patient?
- A. “Alcohol withdrawal is common; we see it all of the tiambierb .icno mth/tees tt rauma unit.”
- B. “There is no way to assess for alcohol withdrawal.”
- C. “This patient will require less pain medication.”
- D. “We have initiated the alcohol withdrawal protocol.”
Correct Answer: D
Rationale: The correct answer is D because initiating the alcohol withdrawal protocol shows an understanding of managing a patient at risk for alcohol withdrawal syndrome. This protocol involves carefully monitoring the patient's symptoms, providing appropriate medications, and ensuring a safe environment. Option A is incorrect as it downplays the seriousness of alcohol withdrawal. Option B is incorrect as there are assessment tools available for identifying alcohol withdrawal. Option C is incorrect as pain management should be tailored to the individual's needs, not necessarily lessened due to alcohol withdrawal risk.
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
- A. Remove the patient’s rings.
- B. Apply ice packs to both hands.
- C. Apply calamine lotion to any itching areas.
- D. Give diphenhydramine (Benadryl) 50 mg PO.
Correct Answer: A
Rationale: The correct answer is A: Remove the patient's rings first. This is crucial to prevent constriction and swelling due to potential allergic reactions or inflammation from bee stings. Removing rings allows for proper circulation and prevents complications like compartment syndrome. Ice packs (B) can be applied after removing the rings to reduce swelling. Calamine lotion (C) can provide relief for itching but is not as urgent as ring removal. Diphenhydramine (D) can be given later for systemic allergic reactions but should not take precedence over removing the rings.