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Which of the following factors predispose the critically ill patient to pain and anxiety? (Select all that apply.)
- A. Inability to communicate
- B. Invasive procedures
- C. Monitoring devices
- D. Preexisting conditions
Correct Answer: A
Rationale: The correct answer is A: Inability to communicate. Critically ill patients often experience pain and anxiety due to their inability to effectively communicate their needs and discomfort. This can lead to unaddressed pain and increased anxiety levels. Choices B, C, and D are incorrect because while invasive procedures, monitoring devices, and preexisting conditions can contribute to pain and anxiety in critically ill patients, they are not factors that directly predispose patients to these issues. It is the lack of communication that significantly hinders the ability to address and manage pain and anxiety effectively in these patients.
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Which nursing interventions would best support the family of a critically ill patient?
- A. Encouraging family members to stay all night in case t he patient needs them.
- B. Giving a condition update each morning and whenever changes occur.
- C. Limiting visitation from children into the critical care u nit.
- D. Providing beverages and snacks in the waiting room.
Correct Answer: B
Rationale: The correct answer is B because giving regular condition updates promotes transparency and communication, reducing anxiety for the family. This intervention helps them stay informed and involved in the patient's care. Choice A may lead to caregiver fatigue and is not sustainable. Choice C limits family support and may increase stress. Choice D focuses on comfort but does not address the family's need for information.
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.
Which nursing strategies help the patient to feel safe in the critical care setting? (Select all that apply.)
- A. Allow family members to remain at the bedside.
- B. Be sure to consult with the charge nurse before making any patient care decisions.
- C. Provide informal conversation by discussing your planasb ifrbo.rc oamf/tteesrt work.
- D. Explain how to communicate for assistance.
Correct Answer: A
Rationale: The correct answer is A because allowing family members to remain at the bedside can provide emotional support and comfort to the patient, helping them feel safe in the critical care setting. Family presence can also facilitate communication and understanding between the healthcare team and the patient.
Choice B is incorrect because consulting with the charge nurse before making patient care decisions may not directly contribute to the patient feeling safe.
Choice C is incorrect because providing informal conversation about work-related topics may not address the patient's need for safety and security in the critical care setting.
Choice D is incorrect because explaining how to communicate for assistance is important for patient care but may not directly contribute to the patient's sense of safety in the critical care setting.
A Muslim woman is admitted to the ICU after suffering severe burns over most of her body. Which of the following would be the most appropriate measure for the nurse, a woman, to take in respect for the cultural practices of this patient?
- A. Insist that only a female doctor be assigned to this patient.
- B. Ensure that no pork products are included in the patients diet.
- C. Ensure that direct eye contact is not made with the patients husband.
- D. Ask the patients husband what religious and cultural preferences should be considered in the patients care.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates respect for the patient's autonomy and individual preferences. By asking the patient's husband about religious and cultural preferences, the nurse acknowledges the importance of involving the family in decision-making and shows sensitivity to the patient's beliefs. This approach promotes cultural competence and patient-centered care.
Choice A is incorrect because insisting on a female doctor may not align with the patient's preferences and may limit the available medical staff. Choice B is also incorrect as dietary restrictions are not necessarily the most pressing issue in this scenario. Choice C is incorrect as it assumes a cultural practice without verifying the patient's specific preferences and may not be necessary or appropriate in this context.
In determining the glomerular filtration rate (GFR) or creatinine clearance, a 24-hour urine is obtained. If a reliable 24-hour urine collection is not possible,
- A. it is not possible to determine the GFR.
- B. the BUN may be used to determine renal function.
- C. an elevated BUN/creatinine ratio can be used.
- D. a standardized formula may be used to calculate GFR.
Correct Answer: D
Rationale: The correct answer is D because when a reliable 24-hour urine collection is not possible, a standardized formula can be used to estimate GFR. The Cockcroft-Gault equation or the Modification of Diet in Renal Disease (MDRD) equation are commonly used formulas to estimate GFR based on serum creatinine levels, age, gender, and race. These formulas provide a reasonable estimation of kidney function in the absence of a 24-hour urine collection.
Choice A is incorrect because there are alternative methods available to estimate GFR. Choice B is incorrect because BUN alone is not sufficient to accurately determine renal function. Choice C is incorrect because an elevated BUN/creatinine ratio is not a direct measure of GFR and may be influenced by factors other than kidney function, such as hydration status or liver function.