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A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent?
- A. Obtain the permission of the custodial parent for the surgery.
- B. Notify the non-custodial parent to also sign a consent form.
- C. Instruct the client sign the consent before giving medications.
- D. Obtain the signature of the client’s stepfather for the surgery.
Correct Answer: A
Rationale: The correct answer is A: Obtain the permission of the custodial parent for the surgery. In this scenario, the client is a minor (16 years old), which means they are not legally able to provide informed consent for medical procedures. The custodial parent holds legal responsibility for the minor's healthcare decisions. Thus, obtaining the permission of the custodial parent is crucial to ensure valid informed consent.
Choice B is incorrect because the non-custodial parent's consent may not be legally required if the custodial parent is available to provide consent. Choice C is incorrect because obtaining consent should precede any administration of medications. Choice D is incorrect as the stepfather's consent may not hold legal weight unless designated as a legal guardian.
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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.
The nurse is preparing for insertion of a pulmonary artery acbairtbh.ceotme/rte (sPt AC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.)
- A. Allay the patient’s anxiety by providing information ab out the procedure.
- B. Ensure that a sterile field is maintained during the inse rtion procedure.
- C. Inflate the balloon during the procedure when indicated by the physician.
- D. Monitor the patient’s cardiac rhythm throughout the en tire procedure.
Correct Answer: B
Rationale: The correct answer is B: Ensure that a sterile field is maintained during the insertion procedure. This is the priority nursing action because maintaining a sterile field is crucial to prevent infection during the invasive procedure. The nurse must follow strict aseptic technique to reduce the risk of introducing bacteria into the patient's bloodstream. All other choices are incorrect: A: Addressing the patient's anxiety is important but not the priority during the insertion procedure. C: Inflating the balloon is a specific action that should be performed by the physician, not the nurse. D: While monitoring the patient's cardiac rhythm is important, ensuring the sterile field takes precedence to prevent complications.
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.
The nurse caring for a mechanically ventilated patient prepares to include which strategies to prevent ventilator-associated pneumonia should be into the patient’s plan of care? (Select all that apply.)
- A. Drain condensate from the ventilator tubing away from the patient.
- B. Elevate the head of the bed 30 to 45 degrees.
- C. Instill normal saline as part of the suctioning procedure.
- D. Perform regular oral care with chlorhexidine.
Correct Answer: A
Rationale: The correct answer is A: Drain condensate from the ventilator tubing away from the patient. This is crucial to prevent ventilator-associated pneumonia as stagnant condensate can harbor harmful bacteria. By draining it away from the patient, the risk of bacterial growth and subsequent aspiration is minimized. Elevating the head of the bed (choice B) helps prevent aspiration but is not specific to preventing ventilator-associated pneumonia. Instilling normal saline during suctioning (choice C) can increase the risk of infection. Performing regular oral care with chlorhexidine (choice D) is important for oral hygiene but not directly related to preventing ventilator-associated pneumonia.
The critical care environment is stressful to the patient. Which interventions assist in reducing this stress? (Select all that apply.)
- A. Adjust lighting to promote normal sleep-wake cycles.
- B. Provide clocks, calendars, and personal photos in the p atient’s room.
- C. Talk to the patient about other patients you are caring for on the unit.
- D. Tell the patient the day and time when you are providi ng routine nursing interventions.
Correct Answer: A
Rationale: Correct Answer: A. Adjust lighting to promote normal sleep-wake cycles.
Rationale:
1. Adjusting lighting can help regulate the patient's circadian rhythm, promoting better sleep and reducing stress.
2. Normal sleep-wake cycles are crucial for overall well-being and healing in a critical care setting.
3. Proper lighting can also create a more calming environment for the patient.
Summary of Incorrect Choices:
B. Providing clocks, calendars, and personal photos can be overwhelming for a stressed patient.
C. Talking about other patients may increase anxiety and breach patient confidentiality.
D. Telling the day and time of routine interventions may disrupt the patient's sense of time and add to stress.