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Which of the following statements regarding pain and anxiety are true? (Select all that apply.)
- A. Anxiety is a state marked by apprehension, agitation, a utonomic arousal, and/or fearful withdrawal.
- B. Critically ill patients often experience anxiety, but they rarely experience pain.
- C. Pain and anxiety are often interrelated and may be diffaibciurbl.tc otmo /tdeisft ferentiate because their physiological and behavioral manifestations are similar.
- D. Pain is defined by each patient; it is whatever the perso n experiencing the pain says it is.
Correct Answer: A
Rationale: Rationale:
A: Correct. Anxiety is characterized by apprehension, agitation, autonomic arousal, and fearful withdrawal, which are distinct from pain.
B: Incorrect. Critically ill patients can experience both anxiety and pain, as pain is not exclusive to them.
C: Incorrect. While pain and anxiety can be interrelated, they can be differentiated based on their unique physiological and behavioral manifestations.
D: Incorrect. Pain is a subjective experience, but it is not solely defined by the individual; objective assessments are also important.
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A patient who is orally intubated and receiving mechanical ventilation is anxious and is fighting the ventilator. Which action should the nurse take next?
- A. Verbally coach the patient to breathe with the ventilator.
- B. Sedate the patient with the ordered PRN lorazepam (Ativan).
- C. Manually ventilate the patient with a bag-valve-mask device.
- D. Increase the rate for the ordered propofol (Diprivan) infusion.
Correct Answer: A
Rationale: The correct answer is A: Verbally coach the patient to breathe with the ventilator. This approach allows the nurse to address the patient's anxiety and help them synchronize their breathing with the ventilator, promoting better ventilation and oxygenation. It is important to first try non-invasive interventions before resorting to sedation or manual ventilation. Sedating the patient (B) should be a last resort to avoid potential complications. Manual ventilation (C) may disrupt the ventilator settings and cause respiratory distress. Increasing the rate of propofol infusion (D) is not indicated unless the patient's sedation level is inadequate.
The primary health care provider writes an order to discon tinue a patient’s left radial arterial line. When discontinuing the patient’s invasive line, what is the priority nursing action?
- A. Apply an air occlusion dressing to insertion site.
- B. Apply pressure to the insertion site for 5 minutes.
- C. Elevate the affected limb on pillows for 24 hours.
- D. Keep the patient’s wrist in a neutral position.
Correct Answer: B
Rationale: The correct answer is B: Apply pressure to the insertion site for 5 minutes. This is the priority nursing action because it helps prevent bleeding and hematoma formation after removing the arterial line. Applying pressure for 5 minutes allows for adequate hemostasis.
A: Applying an air occlusion dressing to the insertion site is not the priority action. It does not address the immediate need to control bleeding.
C: Elevating the affected limb on pillows for 24 hours is not necessary and does not address the immediate need for hemostasis.
D: Keeping the patient's wrist in a neutral position is not the priority action when discontinuing an arterial line. It does not address the need for hemostasis and preventing bleeding.
Noise in the critical care unit can have negative effects on the patient. Which of the following interventions assists in reducing noise levels in the criticala cbiarbr.ec osme/ttetisnt g? (Select all that apply.)
- A. Asking the family to bring in the patient’s i-Pod or other device with favorite music.
- B. Inviting the volunteer harpist to play on the unit on a re gular basis.
- C. Remodeling the unit to have two-patient rooms to facil itate nursing care.
- D. Remodeling the unit to install acoustical ceiling tiles.
Correct Answer: A
Rationale: Step 1: Bringing in the patient's i-Pod with favorite music can provide personalized, soothing sounds, reducing stress and anxiety for the patient.
Step 2: Familiar music can create a calming environment, distracting the patient from external noise.
Step 3: Listening to music may improve patient comfort and overall experience in the critical care unit.
Summary: Option A is correct as it directly addresses noise reduction by providing a personalized, calming environment for the patient. Options B, C, and D do not specifically target noise reduction but focus on other aspects of care or facility improvement.
What is the best way to monitor agitation and effectivenes s of treating it in the critically ill patient?
- A. Confusion Assessment Method (CAM-ICU)
- B. FACES assessment tool
- C. Glasgow Coma Scale
- D. Richmond Agitation Sedation Scale
Correct Answer: D
Rationale: The correct answer is D: Richmond Agitation Sedation Scale (RASS). RASS is specifically designed to monitor agitation and sedation levels in critically ill patients, providing a standardized and objective assessment. It includes clear descriptors for different levels of agitation and sedation, allowing for consistent monitoring and treatment adjustments. CAM-ICU is mainly used for delirium assessment, not agitation. FACES assessment tool is more appropriate for pain assessment. Glasgow Coma Scale is focused on assessing level of consciousness, not agitation specifically. By using RASS, healthcare providers can accurately track agitation levels and evaluate the effectiveness of interventions in managing agitation in critically ill patients.
The AACN Standards for Acute and Critical Care Nursing Practice uses what framework to guide critical care nursing practice?
- A. Evidence-based practice
- B. Healthy work environment
- C. National Patient Safety Goals
- D. Nursing process
Correct Answer: A
Rationale: The correct answer is A: Evidence-based practice. The AACN Standards for Acute and Critical Care Nursing Practice emphasize the use of evidence-based practice to guide critical care nursing. This framework ensures that nursing interventions are based on the best available evidence, leading to improved patient outcomes. Healthy work environment (B) and National Patient Safety Goals (C) are important but not specific frameworks for critical care nursing. The nursing process (D) is a systematic approach to delivering patient care but is not the primary guiding framework in critical care nursing practice.