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Which statement about family assessment is false?
- A. Assessment of structure (who comprises the family) is the last step in assessment.
- B. Interaction among family members is assessed.
- C. It is important to assess communication among family members to understand roles.
- D. Ongoing assessment is important, because family funcatbioirbn.cinomg/ tmesat y change during the course of illness.
Correct Answer: A
Rationale: The correct answer is A because assessing the structure of the family (who comprises the family) is not the last step in family assessment. The rationale is that understanding the family structure is essential at the beginning of the assessment process to identify key relationships and support systems. Assessing interaction among family members helps to understand dynamics and relationships within the family. Assessing communication is crucial to identify roles and patterns of interaction. Ongoing assessment is necessary as family dynamics can evolve throughout the illness. Therefore, A is false as family structure assessment is an important initial step, not the last step.
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Her urine output for the past 2 hours totaled only 40 mL. She arrived from s urgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the past 2 hours, her heart rate has increased from 80 to 100 beats per minute and he r blood pressure has decreased from 128/82 to 100/70 mm Hg. She is being given an infusaiboirnb .coofm n/toesrtm al saline at 100 mL per hour. Her right atrial pressure through the subclavian cen tral line is low at 3 mm Hg. Her urine is concentrated. Her BUN and creatinine levels have been stable and in normal range. Her abdominal dressing is dry with no indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider in creasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the information the nurse gives about the patient’s history and vital signs is appropriate fo r what part of the model?
- A. Situation
- B. Background
- C. Assessment
- D. Recommendation
Correct Answer: C
Rationale: The correct answer is C: Assessment. In the SBAR communication model, the nurse's information about the patient's history and vital signs falls under the Assessment component. This is because the nurse is providing a detailed evaluation of the patient's current condition based on objective data such as urine output, heart rate, blood pressure, and other key indicators. The nurse is analyzing the situation and forming a judgment that the patient is hypovolemic, indicating a fluid deficit. This assessment is crucial for informing further actions or interventions, such as increasing fluids or providing a fluid challenge.
Summary of other choices:
A: Situation - This choice would refer to a brief summary of the current situation without detailed analysis or interpretation.
B: Background - This choice would involve providing relevant background information about the patient, such as medical history or recent procedures, but not the current assessment of the patient's condition.
D: Recommendation - This choice would involve suggesting a course of action or treatment based on the assessment, which comes after
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.
A patient is having difficulty weaning from mechanical ve ntilation. The nurse assesses the patient and notes what potential cause of this difficult weaning?
- A. Cardiac output of 6 L/min
- B. Hemoglobin of 8 g/dL
- C. Negative sputum culture and sensitivity
- D. White blood cell count of 8000
Correct Answer: B
Rationale: The correct answer is B: Hemoglobin of 8 g/dL. Low hemoglobin levels can lead to inadequate oxygen delivery to tissues, causing respiratory distress and difficulty weaning from mechanical ventilation. This is due to reduced oxygen-carrying capacity leading to increased work of breathing.
A: Cardiac output of 6 L/min is within normal range and not directly related to difficulty weaning from mechanical ventilation.
C: Negative sputum culture and sensitivity indicate absence of respiratory infection but not a direct cause of difficulty weaning.
D: White blood cell count of 8000 is within normal range and not a direct cause of difficulty weaning.
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
- A. Remove the patient’s rings.
- B. Apply ice packs to both hands.
- C. Apply calamine lotion to any itching areas.
- D. Give diphenhydramine (Benadryl) 50 mg PO.
Correct Answer: A
Rationale: The correct answer is A: Remove the patient's rings first. This is crucial to prevent constriction and swelling due to potential allergic reactions or inflammation from bee stings. Removing rings allows for proper circulation and prevents complications like compartment syndrome. Ice packs (B) can be applied after removing the rings to reduce swelling. Calamine lotion (C) can provide relief for itching but is not as urgent as ring removal. Diphenhydramine (D) can be given later for systemic allergic reactions but should not take precedence over removing the rings.
The nurse is caring for a very seriously ill patient in the CCU. The family visits sporadically, stays for only a short time, and does not ask many questions. How could the nurse best begin to involve the family in the patients care?
- A. Ask one family member to assist with the patients bath.
- B. Encourage family members to stay longer at each visit.
- C. Focus nursing efforts on the patients legal next of kin.
- D. Ask the family to complete the Critical Care Family Needs Inventory.
Correct Answer: D
Rationale: The correct answer is D: Ask the family to complete the Critical Care Family Needs Inventory. This tool helps assess the family's needs and concerns, enabling the nurse to tailor care accordingly. By understanding the family's specific needs, the nurse can provide appropriate support and information, fostering better involvement and understanding.
A: Asking one family member to assist with the patient's bath may not address the overall family's needs or involvement in care.
B: Encouraging family members to stay longer does not necessarily address their specific needs or facilitate effective communication.
C: Focusing solely on the legal next of kin may exclude important family members who also need support and involvement in the patient's care.