QUESTIONS AND CORRECT

Essentials of Critical Care Nursing Chapter 1 & 2 COMPLETE REVISION

QUESTIONS AND CORRECT

DETAILED ANSWERS (VERIFIED

ANSWERS) ALREADY GRADED A+

The nurse identifies a patient in the critical care unit as having "resiliency." What characteristic has the nurse identified in the patient?

• Motivation to reduce anxiety through positive self-talk
• Ability to bounce back quickly after an insult
• Physical strength to endure extreme physical stressors

4. Ability to return to a state of equilibrium - Answer: 2

The nurse realizes that which stressor is one of the primary concerns of critically ill patients and should be routinely included during assessments?

• Inability to control elimination
• Lack of family support
• Hunger

4. Altered ability to communicate - Answer: 4

A patient has just completed a preoperative education session prior to undergoing coronary artery bypass surgery. Which patient statements indicate that teaching has been effective?Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

• "I understand that I will have to blink my eyes to respond after the breathing tube is in my throat."
• "I will be given frequent mouth care to help me when I am thirsty."
• "I will be able to move about freely in bed and into the chair without help while connected to the

electronic equipment for monitoring."

• "I may need something to help me rest due to the unfamiliar lights and sounds of the ICU unit." 1 / 3

• "I might not behave like my usual self after the surgery but it will be because of the medications and

my illness." - Answer: 1,2,4,5

When providing care to critically ill patients, whether they are responsive or unresponsive, the nurse

should:

• Clearly explain what care is to be done before starting the activity.
• Perform the activity and then let the patient rest without explaining the care.
• Make sure the patient always responds and is cooperative before giving care.
• Explain to the family that the patient will not understand or remember any of the discomfort

associated with care. - Answer: 1

Which communication strategy is most appropriate for a critical care nurse to use when communicating

with a ventilated patient? The nurse should:

• Use professional terminology and provide the patient with detailed information.
• Use simple language and explain in other terms if the patient does not seem to understand.
• Provide minimal information so the patient is not overwhelmed.
• Discuss issues primarily with the family because the patient is unlikely to understand the information.

- Answer: 2

During an assessment, a ventilated patient begins to frown and wiggle about in bed. Which assessment strategy would be most helpful for the nurse to validate these observations?

• Glasgow Scale
• Maslow's hierarchy levels
• Critical-Care Pain Observation Tool (CPOT)

4. Vital signs trends - Answer: 3

Which parameters indicate that a patient in the intensive care unit being mechanically ventilated is

ready for an interruption in sedation? The patient:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

• Had a MAP of 75 and heart rate of 76 2 / 3

• Was sleeping but awakened with verbal stimuli
• Frowned when turned but otherwise showed no muscular tension
• Activated the ventilator alarms but the alarms stopped spontaneously
• Is receiving neuromuscular blocking agents to ensure adequate ventilation - Answer: 1,2,3,4

A patient scores positive on the Confusion Assessment Method of the Intensive Care Unit (CAM-ICU).Which nursing diagnosis would have the highest priority based on this positive score?

• Injury, Risk for
• Family Processes, Altered
• Social Interaction, Impaired

4. Memory Impaired - Answer: 1

Which nursing actions would be appropriate when a nurse is initiating an infusion of morphine sulfate for a post-operative patient who is experiencing pain?

• Anticipate that the patient will begin to experience the effect of the morphine 15 minutes after the

start of the infusion.

• Provide additional intermittent boluses of morphine sulfate if the patient experiences breakthrough

pain.

• Complete the Critical-Care Pain Observation Tool scale 5 minutes after increasing the infusion rate

each time.

• Begin the infusion at the lowest ordered dose and increase the rate every 30 minutes if the patient

continues to have pain. - Answer: 2

Which strategies should the nurse include in the plan of care when trying to minimize sleep disruptions for a patient in an ICU?Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

• Instituting a short course of therapy for sleeping agents
• Accurate scoring and vigilance in sedation and sedation scoring
• Managing the environment to reduce lighting, sounds, and so on
• Minimizing staff interruptions during sleep periods
• / 3