The nurse is caring for a patient who is being evaluated clianbiircba.clolmy/ tfeostr brain death by a primary care provider. Which assessment findings by the nurse sup port brain death?- Skildor

Question 1 of 5

The nurse is caring for a patient who is being evaluated clianbiircba.clolmy/ tfeostr brain death by a primary care provider. Which assessment findings by the nurse sup port brain death?

A. Absence of a corneal reflex B. Unequal, reactive pupils C. Withdrawal from painful stimuli D. Core temperature of 100.8� F

Correct Answer: A

Rationale: The correct answer is A, absence of a corneal reflex, because in brain death, all brainstem reflexes, including the corneal reflex, are absent. This indicates complete loss of brain function. Choice B, unequal reactive pupils, is incorrect as it suggests some level of brainstem function. Choice C, withdrawal from painful stimuli, is also incorrect as it is a spinal reflex and can occur even in the absence of brain function. Choice D, core temperature of 100.8� F, is irrelevant to assessing brain death.

Question 2 of 5

The amount of effort needed to maintain a given level of ventilation is referred to using what term?

A. Compliance B. Resistance C. Tidal volume D. Work of breathing

Correct Answer: D

Rationale: The correct answer is D: Work of breathing. Work of breathing refers to the amount of effort required to maintain a specific level of ventilation. This includes the energy needed for inhalation and exhalation. Compliance (A) refers to the ease with which the lungs expand, resistance (B) is the opposition to airflow in the airways, and tidal volume (C) is the amount of air moved in and out of the lungs during normal breathing. Work of breathing encompasses the overall energy expenditure involved in the breathing process, making it the most appropriate term in this context.

Question 3 of 5

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.

Question 4 of 5

A 15-year-old boy is in the ICU and preparing for an appendectomy. He is clearly anxious and fidgets with his IV constantly. He complains that he doesnt want to be there and he is sick of everyone telling him what to do. What would be the best way for the nurse to address this patients anxiety?

A. Use physical restraints to keep him from pulling out his IV. B. Offer him the remote to the television. C. Lower the head of his bed so that he can rest more easily. D. Explain to the patient in detail what the appendectomy will consist of.

Correct Answer: B

Rationale: The correct answer is B: Offer him the remote to the television. This is the best way to address the patient's anxiety because it provides a distraction and a sense of control, which can help alleviate anxiety. By offering the patient the remote to the television, the nurse is giving him a choice and a way to focus his attention away from his anxiety. This can help him feel more comfortable and empowered in the situation. Choice A is incorrect because using physical restraints can increase the patient's anxiety and sense of helplessness. Choice C, lowering the head of his bed, may provide physical comfort but does not directly address his anxiety. Choice D, explaining the procedure in detail, may further increase his anxiety as it focuses on the surgery rather than addressing his current emotional state.

Question 5 of 5

The patient is complaining of severe flank pain when he tries to urinate. His urinalysis shows sediment and crystals along with a few bacteria. Using this information along with the clinical picture, the nurse realizes that the patient�s condition is

A. prerenal. B. postrenal. C. intrarenal. D. not renal related.

Correct Answer: C

Rationale: The correct answer is C: intrarenal. The presence of sediment, crystals, and bacteria in the urinalysis indicates an issue originating within the kidney itself. This suggests a problem like a urinary tract infection or kidney stone causing the severe flank pain. Prerenal and postrenal conditions usually involve issues outside the kidney such as dehydration or urinary tract obstruction, which are not supported by the urinalysis findings. Choice D, not renal related, is incorrect as the symptoms and urinalysis results clearly point towards a renal issue.

Similar Questions

The patient is complaining of severe flank pain when he tries to urinate. His urinalysis shows sediment and crystals along with a few bacteria. Using this information along with the clinical picture, the nurse realizes that the patient�s condition is

While caring for a patient with a pulmonary artery cathete r, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breat hs/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action?

A 45-year-old postsurgical patient is on a ventilator in the critical care unit has been tolerating the ventilator well and has not required any sedation. The apbairtbi.ecnomt /bteesct omes tachycardic and hypertensive with a respiratory rate that has increased to 28 breaths/min. The ventilator is set on synchronized intermittent mandatory ventilation (SIMV ) at a rate of 10 breaths/min. The patient has been suctioned recently via existing endotracheal tube until airway is clear. When the patient responds appropriately to the nurse�s command s, what should be the nurse�s priority intervention?

The nurse is caring for a mechanically ventilated patient b eing monitored with a left radial arterial line. During the inspiratory phase of ventilation, th e nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse?

A patient is having difficulty weaning from mechanical ve ntilation. The nurse assesses the patient and notes what potential cause of this difficult weaning?

Critical Care Nursing Questions and Answers PDF

Skildor

ATI RN