Test Bank For Critical Care Nursing: A Holistic Approach, 10th Edition

Chapter 2- The Patient’s Experience With Critical illness 1. The critical care unit environment is very stressful for patients, families, and staff. What nursing action is directed at reducing environmental stress? A) Constant evaluation of patient status B) Limiting visits to immediate family C) Bathing all patients during hours of sleep D) Maintaining quiet during hours of sleep 2. A patient is transferred to the ICU from the Birth Center of the hospital in the middle of the night after experiencing complications during delivery of her baby. The patient’s husband is anxious and explains to the ICU nurse that he doesn’t understand why his wife has been moved to the ICU. “ She is going to die, isn’t she?” he asks the nurse. What is the nurse’s best response? A) Explain that every measure will be taken to provide his wife with the best care possible. B) Explain that the nurse is fully trained and has years of experience. C) Offer the husband a place to relax. D) Have appropriate staff discuss his health insurance with him. 3. A patient is admitted to the ICU with injuries sustained from a fall from a third-story window. The patient is conscious, his breathing is labored, and he is bleeding heavily from the abdomen. He groans constantly and complains of severe pain, but his movements are minimal. His heart rate is elevated. Which of these is a sign that he is in the second phase of the stress response? Select all that apply. A) Bleeding heavily from his abdomen B) Labored, slow breathing C) Severe pain D) Elevated heart rate E) Minimal movement 4. A patient in the ICU is recovering from open-heart surgery. The nurse enters his room and observes that his daughter is performing effleurage on his arms and talking in a low voice about an upcoming family vacation that is planned. The room is dimly lit, and she hears the constant beeping of his heart monitor. From the hall she hears the cries of a patient in pain. Which of the following are likely stressors for the patient? Select all that apply. A) His daughter’s conversation B) His daughter’s effleurage C) The beeping of the heart monitor D) The dim lighting of the room E) The cries of the other patient from the hall 5. A patient in the ICU is complaining that he is not sleeping well at night because of anxiety. Which of the following would be the most helpful intervention for the nurse to make? A) Provide the patient with a bath immediately following his first 90-minute REM sleep cycle. B) Increase the patient’s pain medication. C) Provide the patient with 5 minutes of effleurage and then minimize disruptions. D) Monitor the patient’s brain waves by polysomnography to determine his sleep pattern. 6. A nurse walks into a patient’s room and begins preparing a syringe to perform a blood draw on the patient. The nurse observes that the patient is firmly gripping the side of the bed, averting her eyes, and sweating from her forehead when she sees the needle. What would be the best intervention for the nurse to make? A) Proceed with blood draw as quickly as possible, to get it over with. B) Offer to come back later to perform the blood draw. C) Encourage the patient to deep breathe. D) Describe briefly the blood draw procedure and explain why it is necessary. 7. 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 doesn’t 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 patient’s 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. 8. A nurse in a burn unit observes that a patient is tensed up and frowning but silent. The nurse asks the patient, “ Can you tell me what you are thinking now?” The patient responds, “ I can’t take this pain any more! I feel like I’m about to die.” What would be the best response for the nurse to give to the patient, considering that the patient is already receiving the maximum amount pain medication that is safe? A) “ Try to get rid of those negative thoughts—they only make it worse.” B) “ Try thinking instead, ‘This pain will go away; I can overcome it.’” C) “ Your pain medication is already at the highest possible dose.” D) “ Would you like me to raise the head of your bed?” 9. A patient on mechanical ventilation is experiencing severe agitation due to being on the ventilator. Which nursing intervention would be best? A) Performing breathing exercises with the patient B) Offering the patient a patient-controlled analgesic device C) Asking the physician to prescribe an antianxiety medication D) Offering the patient the patient’s own MP3 player to listen to 10. A 10-year-old female patient in ICU receiving chemotherapy has requested that her dog be allowed to visit her. She is currently sharing a room with another patient. The nurse knows that the hospital does allow for pet visits with owners, but has strict guidelines. Which of the following scenarios is most likely to be permitted? A) The girl’s father may bring the dog in on a leash for a 20-minute visit. B) The girl’s sister may bring the dog in with a shirt on (to prevent shedding) for an overnight stay. C) The girl’s mother may bring the dog in on a leash for a visit as long as he has had all his vaccinations. D) The dog may be brought in for a brief visit once the girl is moved to a private room. 11. The nurse understands that a patient being cared for in a critical care unit experiences an acute stress response. What nursing action best demonstrates understanding of the physiological parts of the initial stress response? A) Adequate pain control B) Intravenous sedation C) Treatment for elevated blood pressure D) Ignoring an elevated glucose level 12. A critically ill patient experiences stress and anxiety from many factors. Treatment of the patient focuses on reducing stressors and providing supportive care such as nutrition, oxygenation, pain management, control of anxiety, and specific care of the illness or injury. What is the best rationale for these interventions? A) Helps to support the patient’s immune system B) Part of good nursing care C) Mandated by hospital policy D) Reassures the patient and family 13. A patient in a critical care unit has increased stress from the constant noise and light levels. What nursing intervention best attenuates these sources of stress? A) Need for constant observation and evaluation B) Dimming lights during the night C) Frequent nursing group rounds for all patients D) Use of tile floors for ease in cleaning 14. The nurse is caring for a patient who is orally intubated and on a mechanical ventilator. The nurse believes that the patient is experiencing excess anxiety. For this patient, what behavior best indicates anxiety? A) Restlessness B) Verbalization C) Increased respiratory rate D) Glasgow Coma Scale score of 3 15. The critical care unit environment is very stressful for patients, families, and staff. What nursing action is directed at reducing environmental stress? A) Constant expert evaluation of patient status B) Limiting visits to immediate family C) Bathing all patients during hours of sleep D) Maintaining a quiet environment during hours of sleep 16. The nurse wishes to enhance sleep cycles in her critically ill patient. Research has shown that which nursing action improves sleep in critically ill patients? A) Repositioning every 2 hours B) Hypnotic medications C) Five-minute back effleurage D) Adequate pain control 17. The nurse is caring for a critically ill patient with a very concerned family. Given that the family is under high stress, what nursing intervention will best ameliorate their stress while preserving independence? A) Encourage the family to participate in patient care tasks. B) Teach the family to ask questions of the health care team. C) Ask the family to select a family representative for communication. D) Limit visits to immediate family members for limited times. 18. While caring for a critically ill patient, the nurse knows that fostering patient control over the environment is a method for stress reduction. What nursing intervention gives the patient the most environmental control while still adhering to best practice principles? A) Ask the patient whether he or she wants to get out of bed. B) Give the patient’s bath at the same time every day. C) Explain painful procedures only after giving pain medication. D) Choose menu items for the patient to ensure a balanced diet. 19. The nurse is using presence to reduce the anxiety of a critically ill patient. What nursing behavior demonstrates an effective use of presence? A) Staying in the patient’s room to complete documentation B) Having a conversation in the patient’s room that excludes the patient C) Maintaining eye contact with the patient during explanations D) Focusing on specific nursing care tasks while in the patient’s room 20. The nurse is caring for a critically ill patient who can speak. The nurse notices that the patient is demonstrating behaviors indicative of anxiety but is silent. What nursing strategy would give the nurse the most information about the patient’s feelings? A) Explain procedures to the patient and family. B) Ask the patient to share his or her internal dialogue. C) Encourage the patient to nap before visiting hours. D) Ensure that the patient has adequate pain control. 21. The patient is undergoing a necessary but painful procedure that is greatly increasing her anxiety. The nurse decides to use guided imagery to help alleviate the patient’s anxiety. What is a key part of this technique? A) Provide the patient with an external focus point such as a picture. B) Have the patient take slow, shallow breaths while staring at a focus point. C) Have the patient remember tactile sensations of a pleasant experience. D) Encourage the patient to consciously relax all of her muscles. 22. One of the strategies shown to reduce perception of stress in critically ill patients and their families is support of spirituality. What nursing action is most clearly supportive of the patient’s spirituality? A) Referring patients to the Catholic chaplain B) Providing prayer booklets to patients and families C) Asking about beliefs about the universe D) Avoiding discussing religion with those of other faiths 23. A critically ill patient tells the nurse that he is not afraid to die because he believes in reincarnation. What is the most appropriate nursing response? A) “ What if reincarnation is not real?” B) “ This belief gives you strength.” C) “ I don’t believe in reincarnation.” D) “ You shouldn’t base your hopes on such a belief.” 24. A critically ill patient who is intubated and agitated is restrained with soft wrist restraints. Based on research findings, what is the best nursing action? A) Maintain the restraints to protect patient safety. B) Remove the restraints periodically to check skin integrity. C) Remove the restraints periodically for range of motion. D) Assess and intervene for causes of agitation. Answer Key 1. D 2. A 3. C, E 4. C, E 5. C 6. D 7. B 8. B 9. D 10. D 11. A 12. A 13. B 14. A 15. D 16. C 17. B 18. B 19. C 20. B 21. C 22. C 23. B 24. D Page 1