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Which of the following is the INITIAL eaching given to the patient with ALS and her family?
- A. Referral to support group
- B. Prevention of complications
- C. Explaining the disease process, expected course and prognosis
- D. Prevention of depression
Correct Answer: C
Rationale: The initial teaching given to a patient with ALS and her family should focus on explaining the disease process, the expected course, and prognosis. Providing this information early on can help the patient and her family understand what to expect, make informed decisions about care and treatment, and prepare emotionally for the challenges ahead. It is important to establish open communication and provide support from the beginning to help the patient and her family cope with the diagnosis and navigate the journey with ALS. While referral to support groups, prevention of complications, and prevention of depression are all important aspects of care for ALS patients, understanding the disease process and prognosis is fundamental to setting realistic expectations and planning for the future.
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What nursing diagnosis would be MOST appropriate for a client admitted with heart failure?
- A. Risk for denial
- B. Ineffective tissue perfusion
- C. Impaired gas exchange
- D. Acute pain
Correct Answer: B
Rationale: Heart failure is a condition in which the heart is unable to pump enough blood to meet the body's need for oxygen and nutrients. Ineffective tissue perfusion is a relevant nursing diagnosis for a client with heart failure because the heart's inability to effectively pump blood can lead to poor perfusion of tissues and organs, resulting in inadequate oxygen and nutrient delivery to cells. This can lead to symptoms such as fatigue, dyspnea, and edema, which are common in individuals with heart failure. By addressing ineffective tissue perfusion, nurses can focus on interventions to improve cardiac output and optimize tissue perfusion, ultimately improving the client's overall condition.
A patient in the ICU develops acute respiratory distress syndrome (ARDS) with severe hypoxemia refractory to conventional oxygen therapy. What intervention should the healthcare team prioritize to improve the patient's oxygenation?
- A. Initiate prone positioning to optimize lung recruitment.
- B. Administer inhaled pulmonary vasodilators for vasodilation.
- C. Perform recruitment maneuvers to open collapsed alveoli.
- D. Recommend extracorporeal membrane oxygenation (ECMO) for respiratory support.
Correct Answer: D
Rationale: In the scenario described, the patient is experiencing severe hypoxemia refractory to conventional oxygen therapy, indicating a need for advanced respiratory support. When a patient with ARDS fails to respond to conservative management, including mechanical ventilation strategies, prone positioning, and recruitment maneuvers, the next step may involve extracorporeal membrane oxygenation (ECMO). ECMO provides a way to bypass the lungs and oxygenate the blood directly, allowing for enhanced gas exchange and support for severely compromised respiratory function. Therefore, in this critical situation, prioritizing the recommendation for ECMO can offer the patient the best chance of improving oxygenation and survival.
A patient with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with acute exacerbation and respiratory failure requiring mechanical ventilation. Which of the following ventilator settings is most appropriate for minimizing the risk of ventilator-induced lung injury (VILI) in this patient?
- A. Low tidal volume and high positive end-expiratory pressure (PEEP)
- B. High tidal volume and low respiratory rate
- C. Spontaneous breathing mode with pressure support ventilation (PSV)
- D. Synchronized intermittent mandatory ventilation (SIMV)
Correct Answer: A
Rationale: Patients with COPD are at increased risk for developing ventilator-induced lung injury (VILI) due to their underlying lung pathology. Using a low tidal volume strategy (6-8 ml/kg predicted body weight) has been shown to reduce the risk of VILI in these patients. Additionally, applying high positive end-expiratory pressure (PEEP) helps to recruit collapsed alveoli, improve oxygenation, and decrease the risk of barotrauma by keeping the alveoli open throughout the respiratory cycle. Therefore, the most appropriate ventilator settings to minimize the risk of VILI in a COPD patient with acute exacerbation and respiratory failure requiring mechanical ventilation would be low tidal volume and high PEEP.
A woman in active labor has a prolonged second stage with inadequate expulsive efforts. What nursing intervention is appropriate to facilitate fetal descent?
- A. Encourage the mother to push forcefully during contractions.
- B. Apply fundal pressure to assist with fetal descent.
- C. Prepare for immediate cesarean section.
- D. Administer intravenous magnesium sulfate for uterine relaxation.
Correct Answer: B
Rationale: In the scenario of a woman in active labor experiencing a prolonged second stage with inadequate expulsive efforts, the appropriate nursing intervention to facilitate fetal descent would be to apply fundal pressure. Fundal pressure, or applying pressure on the upper abdomen just above the uterine fundus, can help in directing the fetal head downwards and aiding in the descent through the birth canal. It is important to note that fundal pressure should be applied carefully and with proper technique to prevent excessive force that could potentially harm the mother or the baby. Encouraging the mother to push forcefully during contractions can be helpful, but the addition of fundal pressure can provide extra assistance in cases of inadequate progress. Immediate cesarean section may be considered if other interventions are unsuccessful or if there are concerns for fetal distress. Administering intravenous magnesium sulfate for uterine relaxation is not indicated in this situation.
Primary care nursing is organized so that the patient is at the center of the structure. How many nurses have 24-hour responsibility for care planning and coordination?
- A. One
- B. Three
- C. Two
- D. Four
Correct Answer: A
Rationale: In primary care nursing, typically, one nurse is designated to have 24-hour responsibility for care planning and coordination for each patient. This helps ensure continuity of care and accountability. By having one nurse overseeing all aspects of the patient's care, it allows for a more personalized and coordinated approach that puts the patient at the center of the care structure. Having one primary care nurse also promotes better communication, efficiency, and consistency in managing the patient's health and well-being.