Correct Answer: D

Rationale: The correct answer is D: Richmond Agitation Sedation Scale (RASS). RASS is specifically designed to monitor agitation and sedation levels in critically ill patients, providing a standardized and objective assessment. It includes clear descriptors for different levels of agitation and sedation, allowing for consistent monitoring and treatment adjustments. CAM-ICU is mainly used for delirium assessment, not agitation. FACES assessment tool is more appropriate for pain assessment. Glasgow Coma Scale is focused on assessing level of consciousness, not agitation specifically. By using RASS, healthcare providers can accurately track agitation levels and evaluate the effectiveness of interventions in managing agitation in critically ill patients.

Correct Answer: A

Rationale: The correct answer is A because it respects the patient's right to privacy while also acknowledging the family's presence. By asking family members if they wish to remain in the room, the nurse allows them to make an informed decision based on their comfort level. This approach fosters open communication and shows respect for the family's emotions.


Choice B is incorrect because abruptly removing family members can increase their distress and feelings of powerlessness.
Choice C is incorrect as it places the burden of support solely on a staff member, potentially isolating the family from the situation.
Choice D is incorrect as it assumes family members should stay without considering their preferences or emotional well-being.

Correct Answer: D

Rationale: The correct answer is D: Sense of loss of control of the situation. The wife's demand to reassign the nurse indicates her need for control over her husband's care, as she may feel overwhelmed by the sudden cardiac arrest and hospitalization. By requesting a different nurse, she seeks to regain a sense of control and assurance. The other choices are incorrect because: A does not align with the wife's immediate concern, B does not explain her request for a nurse reassignment, and C does not address her emotional response to the situation.

Correct Answer: C

Rationale: The correct answer is C because the patient with AIDS-related dementia requires palliative care and pain management, which are key components of hospice care. This patient is likely in the terminal stage of their illness and would benefit from the comprehensive support provided by hospice services.


Choice A is incorrect because the patient's children's inability to discuss dying issues does not necessarily indicate a need for hospice care.
Choice B is incorrect as chronic severe pain due to spinal arthritis is not a sole criterion for hospice referral.
Choice D is incorrect as advanced liver failure alone does not automatically qualify a patient for hospice care.

Correct Answer: A

Rationale: The stroke volume is calculated by dividing the cardiac output by the heart rate. Given the cardiac output of 4.7 L/min and a heart rate of 87 bpm, the stroke volume is 54 mL (4700 mL/87 bpm ≈ 54 mL).
Therefore, choice A (54) is the correct answer.

Choices B, C, and D are incorrect as they do not match the calculated stroke volume based on the provided cardiac output and heart rate.