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Which of the following statements describes the core conc ept of the synergy model of practice?
- A. All nurses must be certified in order to have the synerg y model implemented.
- B. Family members must be included in daily interdisciplaibnirabr.cyo mro/teusnt ds.
- C. Nurses and physicians must work collaboratively and synergistically to influence care.
- D. Unique needs of patients and their families influence nursing competencies.
Correct Answer: D
Rationale: Rationale:
D is correct because the synergy model focuses on individualized care based on patients' unique needs. This model emphasizes tailoring nursing competencies to address these needs, promoting holistic care. A is incorrect as certification is not a requirement. B involves family inclusion but does not capture the core concept. C mentions collaboration but does not specifically address individualized care.
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The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle crash. The patient’s Glasgow Coma Score is 3 anda binirbte.cromm/ittetset ntly withdraws when painful stimuli are introduced. The patient is ventilator dependent and occasionally takes a spontaneous breath. The primary care provider explains to the family that the patient has severe neurological impairment and it is not expected that the patient will ever recover consciousness. What concept does this situation depict?
- A. An organ donor
- B. Brain death
- C. A persistent vegetative state
- D. Terminally ill
Correct Answer: C
Rationale: The correct answer is C: A persistent vegetative state. This choice is correct because the patient exhibits minimal responsiveness, only withdrawing to painful stimuli, and lacks meaningful interaction or consciousness. A persistent vegetative state is characterized by preserved wakefulness without awareness, which aligns with the patient's condition.
Choice A: An organ donor is incorrect because the patient's neurological impairment does not necessarily indicate readiness for organ donation.
Choice B: Brain death is incorrect because the patient still exhibits some reflexive responses, indicating a level of brain function beyond brain death.
Choice D: Terminally ill is incorrect as it does not specifically address the patient's neurological status and prognosis, which is better described by a persistent vegetative state.
When fluid is present in the alveoli what is the result?
- A. Alveoli collapse and atelectasis occurs.
- B. Diffusion of oxygen and carbon dioxide is impaired.
- C. Hypoventilation occurs.
- D. The patient is in heart failure.
Correct Answer: A
Rationale: The correct answer is A: Alveoli collapse and atelectasis occurs. When fluid is present in the alveoli, it impairs the surface tension necessary for the alveoli to remain open, leading to collapse and atelectasis. This prevents proper gas exchange, resulting in hypoxemia. Choice B is incorrect because impaired gas diffusion typically occurs with conditions affecting the alveolar-capillary membrane, not fluid in the alveoli. Choice C is incorrect as hypoventilation refers to decreased ventilation, not specifically related to fluid in the alveoli. Choice D is incorrect as fluid in the alveoli is not a direct indicator of heart failure.
A patient requires neuromuscular blockade (NMB) as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes which interventions? (Select all that apply.)
- A. Administration of sedatives concurrently with neuromuscular blockade.
- B. Dangling the patient’s feet over the edge of the bed an d assisting the patient to sit up in a chair at least twice each day.
- C. Ensuring that deep vein thrombosis prophylaxis is initi ated.
- D. providing interventions for eye care, oral care, and skin care.
Correct Answer: C
Rationale: The correct answer is C: Ensuring that deep vein thrombosis prophylaxis is initiated. When a patient requires neuromuscular blockade for increased intracranial pressure, they are likely immobile, which increases the risk of deep vein thrombosis (DVT). Initiating DVT prophylaxis, such as compression stockings or anticoagulant therapy, helps prevent blood clot formation.
Choice A is incorrect because sedatives can mask signs of neurologic deterioration in this patient population. Choice B is incorrect as it promotes activities that may increase intracranial pressure and could be harmful. Choice D, while important for overall patient care, is not directly related to the specific nursing interventions required for a patient receiving neuromuscular blockade for increased intracranial pressure.
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.
The nurse is assigned to care for a patient who is a non-na tive English speaker. What is the best way to communicate with the patient and family to provide updates and explain procedures?
- A. Conduct a Google search on the computer to identify resources for the patient and family in their native language. Print these for their use .
- B. Contact the hospital’s interpreter service for someone to translate.
- C. Get in touch with one of the residents that you know is fluent in the native language and ask him if he can come up to the unit.
- D. Use a young family member who is fluent in both English and the native language to translate for you.
Correct Answer: B
Rationale: The correct answer is B: Contact the hospital’s interpreter service for someone to translate. This is the best option as it ensures accurate communication between the nurse, patient, and family. Hospital interpreters are trained professionals who can accurately convey medical information, ensuring understanding and informed decision-making. Using Google search (A) may result in inaccurate information and is not reliable for medical communication. Asking a resident (C) who is fluent may not guarantee accuracy in medical terminology. Using a young family member (D) as a translator can lead to miscommunication due to potential language barriers or lack of medical knowledge. Overall, option B is the most appropriate and ethical choice for effective communication in a healthcare setting.