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?

Correct Answer: A

Rationale: The correct answer is A: Helps to support the patient's immune system. Providing supportive care such as nutrition, oxygenation, pain management, and anxiety control can help reduce stress, which in turn supports the immune system. Stress weakens the immune system, making the patient more vulnerable to infections and complications. By addressing stress and anxiety through supportive care, the patient's immune system is better able to function optimally, aiding in the recovery process. Choices B, C, and D are incorrect because: B: Part of good nursing care - While supportive care is indeed part of good nursing care, the key rationale for these interventions in a critically ill patient is to support the immune system, not just to provide good nursing care. C: Mandated by hospital policy - Hospital policies may dictate certain aspects of care, but the primary goal of these interventions is to support the patient's immune system, not just to comply with hospital policies. D: Reassures the patient and family - While providing reass

Correct Answer: B

Rationale: The correct answer is B: Equal bilateral breath sounds upon auscultation. This indicates proper placement of the endotracheal tube in the trachea, ensuring both lungs are being ventilated equally. Rationale: 1. Auscultation of air over the epigastrium (Choice A) is incorrect as it indicates esophageal intubation, not tracheal intubation. 2. Position above the carina verified by chest x-ray (Choice C) is incorrect as it does not confirm proper placement at the trachea. 3. Positive detection of carbon dioxide (CO2) (Choice D) is incorrect as it indicates the presence of exhaled CO2, but not necessarily proper placement in the trachea.

Correct Answer: B

Rationale: The correct answer is B: Because the patient is unconscious, complete care as quickly and quietly as possible. This is the most appropriate intervention as it prioritizes the patient's comfort and minimizes unnecessary stimulation. Performing care quickly reduces the time the patient is exposed to potentially uncomfortable procedures. Being quiet also helps create a calming environment for the patient, which is important for someone who is unresponsive. Explanation for other choices: A: Asking a family member to help and discussing family structure is not appropriate as it can be intrusive and may not be relevant or beneficial to the patient's care. C: Informing the patient of the day and time is unnecessary as the patient is unresponsive. Providing care is more crucial than updating the patient. D: Turning on the television is inappropriate as it introduces unnecessary noise and distraction, which can be overwhelming for an unresponsive patient.

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Limiting visitation to reduce emotional distress contradicts the principles of effective end-of-life care, which emphasize holistic support for the patient and family. 2. Effective end-of-life care encourages open communication and emotional support from loved ones. 3. Limiting visitation may hinder emotional closure and support for both the patient and family. 4. Options A, C, and D align with effective end-of-life care by focusing on symptom management, education, and spiritual support for the patient and family.

Correct Answer: E

Rationale: The correct answer is not provided, but based on the events described, the official time of death recorded in the medical record should be 1810 (Choice D). At this time, the cardiac monitor shows flatline, indicating the cessation of cardiac activity, which is the universally accepted point of declaring death. Choice A (1300) is incorrect because that is when diagnostic tests for brain death were completed, but the patient was not officially declared dead at that time. Choice B (1330) is incorrect as this is when the primary care provider reviewed the test results and documented brain death in the progress note, but the patient was not officially declared dead at this time either. Choice C (1400) is incorrect as there is no significant event occurring at this time that signifies the patient's death. Therefore, the most appropriate and official time of death recorded in the medical record would be 1810 when the cardiac monitor shows flatline.

Correct Answer: A

Rationale: The correct answer is A because nociceptors are specialized nerve receptors that do not adapt much to continual pain response. This lack of adaptation allows nociceptors to continuously signal the presence of tissue-damaging stimuli, which is crucial for the perception of pain. Choices B, C, and D are incorrect because nociceptors do not inhibit the infiltration of neutrophils and eosinophils (B), they do play a role in the inflammatory response (C), and they transmit various types of stimuli including thermal, mechanical, and chemical, not just thermal stimuli (D).

Correct Answer: C

Rationale: The correct answer is C: Anxiety about unfinished business. The patient's desire to settle issues with their siblings before death indicates a concern about unresolved matters. This response aligns with the concept of psychosocial responses to death, specifically the need for closure and resolution. Restlessness (choice A) may not necessarily indicate a specific focus on unfinished business. Yearning and protest (choice B) typically refer to the initial stages of grief, not specifically related to settling unresolved issues. Fear of the meaninglessness of one's life (choice D) is more existential and philosophical, whereas the patient's focus here is on addressing specific issues with their siblings.

Correct Answer: D

Rationale: The correct answer is D: Titrate to a predefined endpoint using a standard sedation scale. This approach ensures individualized dosing based on the patient's response, minimizing the risk of over-sedation or under-treatment. It allows for careful monitoring and adjustment of dosage to achieve the desired level of sedation while avoiding adverse effects. A: Administering medication around the clock may lead to unnecessary sedation and increased risk of side effects. B: Administering medications through a feeding tube is not recommended for benzodiazepines as it may affect absorption and increase the risk of complications. C: Giving the highest allowable dose without considering individual response can result in excessive sedation and adverse effects.

Correct Answer: A

Rationale: The correct answer is A because comparing measured pressures with other physiological parameters ensures accuracy and consistency. This step helps in interpreting the RA P/CVP reading correctly. Choice B is incorrect as flushing the catheter with saline is not necessary for obtaining the pressure reading. Choice C is incorrect as inflating the balloon with air is not part of the correct procedure. Choice D is incorrect because obtaining the measurement during exhalation can affect the accuracy of the reading.