NCLEX Critical Care Concepts
COMPLETE REVISION QUESTIONS
AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) ALREADY
GRADED A+
A nurse in the intensive care unit (ICU) is caring for a client with sepsis who is on a mechanical ventilator (MV). The client is exposed to the noise of the MV, monitoring equipment, and infusion pump alarms during the day and night. What should the nurse identify as the priority nursing diagnosis (ND)?
- Anxiety
- Disturbed sleep pattern
- Powerlessness
4. Risk for acute confusion - Answer: 2
A disturbance in sleep pattern refers to time-limited interruptions of the amount and quality of a client's sleep due to external factors (eg, noise, lighting, noxious odors, interruptions due to medical and nursing care). Evidence shows that excessive noise and sleep disturbances in critically ill clients can affect outcomes as they can lead to significant psychologic (eg, delirium, post-traumatic stress disorder, anxiety) and physiologic (eg, circadian rhythm disturbance, decreased REM sleep, increased heart rate, impaired immunity) consequences.Sleep disturbance pattern can lead to anxiety, powerlessness, and acute confusion. Therefore, disturbed sleep pattern related to environmental factors such as excessive noise and changes in daylight-darkness exposure (circadian rhythm disturbance) is the priority ND.(Option 1) Anxiety in the ICU client is most often associated with pain and fear of the unknown and can be an appropriate ND. However, it is not the priority ND for this client.(Option 3) Powerlessness is the sense of lack of control over a situation, such as requiring critical care for a life-threatening condition, and can be an appropriate ND. However, it is not the priority ND for this client.
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