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A 15-year-old boy is in the ICU and preparing for an appendectomy. He is clearly anxious and fidgets with his IV constantly. He complains that he doesnt want to be there and he is sick of everyone telling him what to do. What would be the best way for the nurse to address this patients anxiety?
- A. Use physical restraints to keep him from pulling out his IV.
- B. Offer him the remote to the television.
- C. Lower the head of his bed so that he can rest more easily.
- D. Explain to the patient in detail what the appendectomy will consist of.
Correct Answer: B
Rationale: The correct answer is B: Offer him the remote to the television. This is the best way to address the patient's anxiety because it provides a distraction and a sense of control, which can help alleviate anxiety. By offering the patient the remote to the television, the nurse is giving him a choice and a way to focus his attention away from his anxiety. This can help him feel more comfortable and empowered in the situation.
Choice A is incorrect because using physical restraints can increase the patient's anxiety and sense of helplessness. Choice C, lowering the head of his bed, may provide physical comfort but does not directly address his anxiety. Choice D, explaining the procedure in detail, may further increase his anxiety as it focuses on the surgery rather than addressing his current emotional state.
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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.
The nurse is using presence to reduce the anxiety of a critically ill patient. What nursing behavior demonstrates an effective use of presence?
- A. Staying in the patients room to complete documentation
- B. Having a conversation in the patients room that excludes the patient
- C. Maintaining eye contact with the patient during explanations
- D. Focusing on specific nursing care tasks while in the patients room
Correct Answer: C
Rationale: The correct answer is C because maintaining eye contact with the patient during explanations is a non-verbal way to show attentiveness and empathy, which can help reduce the patient's anxiety. This behavior demonstrates active listening and engagement, making the patient feel heard and understood.
A: Staying in the patient's room to complete documentation is not an effective use of presence as it does not involve direct interaction with the patient.
B: Having a conversation in the patient's room that excludes the patient is also not an effective use of presence as it does not involve engaging with the patient.
D: Focusing on specific nursing care tasks while in the patient's room, although important, may not necessarily demonstrate presence in reducing the patient's anxiety.
What does pulse oximetry measure?
- A. Arterial blood gases
- B. Hemoglobin values
- C. Oxygen consumption
- D. Oxygen saturation
Correct Answer: D
Rationale: Pulse oximetry measures oxygen saturation in the blood by analyzing the absorption of light by hemoglobin. Oxygen saturation indicates the percentage of hemoglobin molecules carrying oxygen. This is essential for assessing respiratory function and oxygen delivery to tissues. Arterial blood gases (Choice A) directly measure oxygen and carbon dioxide levels in the blood, not specifically oxygen saturation. Hemoglobin values (Choice B) provide information about the amount of hemoglobin present but not its oxygen-carrying capacity. Oxygen consumption (Choice C) is a measure of how much oxygen is used by tissues, not what pulse oximetry directly measures.
When assessing the patient for hypoxemia, the nurse recognizes what as an early sign of the effect of hypoxemia on the cardiovascular system?
- A. Heart block
- B. Restlessness
- C. Tachycardia
- D. Tachypnea
Correct Answer: C
Rationale: The correct answer is C: Tachycardia. Hypoxemia results in decreased oxygen levels in the blood, stimulating the body to increase heart rate to improve oxygen delivery. Tachycardia is an early sign of the cardiovascular system compensating for hypoxemia. Heart block (A) is a disruption in the electrical conduction within the heart and is not directly related to hypoxemia. Restlessness (B) is a non-specific sign and can be caused by various factors. Tachypnea (D) is an increased respiratory rate, which is a response to hypoxemia but not a direct effect on the cardiovascular system.
A physician visits a patient in the ICU while the nurse is out. The patient complains that the pain medication is not effective and that he would like to receive an increased dose. The physician has the nurse paged and consults with him in the hallway regarding the patients request for stronger pain medication. The nurse explains that patient was started on a morphine drip only 20 minutes ago and that the drug has not had time to take effectyet. The physician agrees and tells the patient to give it just a bit more time. Which component of a healthy work environment is most evident in this scenario?
- A. Skilled communication
- B. Appropriate staffing
- C. True collaboration
- D. Recognizing signs of imminent stroke and paging the physician
Correct Answer: C
Rationale: The correct answer is C: True collaboration. In this scenario, the physician consults with the nurse to understand the situation and collaborates on the best course of action for the patient's care. This demonstrates effective teamwork, communication, and mutual respect between healthcare professionals, which are key components of a healthy work environment.
Choice A (Skilled communication) is not the best answer because while communication between the physician and nurse is important, the focus in this scenario is more on collaboration and teamwork.
Choice B (Appropriate staffing) is not the best answer as the scenario does not specifically address staffing levels but rather the interaction and collaboration between the physician and nurse.
Choice D (Recognizing signs of imminent stroke and paging the physician) is incorrect as it is unrelated to the scenario described, which is about the physician and nurse collaborating on patient care.