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.

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Critical Care Nursing Cardiac Questions Questions

Question 1 of 5

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.

Correct Answer: C

Rationale: The correct answer is C: The beeping of the heart monitor is a likely stressor for the patient recovering from open-heart surgery in the ICU. The constant beeping can cause anxiety and uncertainty about their health status. The daughter's conversation and effleurage are likely comforting and supportive for the patient, reducing stress. The dim lighting may create a calming environment, and the distant cries of a patient in pain may evoke empathy but may not directly stress the recovering patient. Therefore, the beeping of the heart monitor stands out as a stressor among the choices provided.

Question 2 of 5

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?

Correct Answer: D

Rationale: The correct answer is D: Adequate pain control. Pain can significantly disrupt sleep in critically ill patients. By ensuring adequate pain control, the nurse can help improve the patient's ability to rest and sleep. This intervention targets a key factor affecting sleep cycles in critically ill patients. Repositioning every 2 hours (A) may help prevent pressure ulcers but does not directly address sleep improvement. Hypnotic medications (B) may have adverse effects and are not recommended as a first-line intervention. Five-minute back effleurage (C) may provide temporary relaxation but is not as effective as adequate pain control in improving sleep quality.

Question 3 of 5

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 patients spirituality?

Correct Answer: C

Rationale: The correct answer is C because asking about beliefs about the universe allows the nurse to understand the patient's spiritual needs and provide appropriate support. This action shows respect for the patient's beliefs and can help establish a connection between the patient and the nurse. Referring patients to a specific religious figure (choice A) may not align with the patient's beliefs. Providing prayer booklets (choice B) assumes the patient's belief system and may not be helpful. Avoiding discussing religion (choice D) can hinder the nurse-patient relationship and overlook potential sources of support for the patient.

Question 4 of 5

A new nurse has recently joined the ICU from a different hospital, which had a much stricter policy regarding visiting hours. She expresses concern about the impact of open visiting hours on patient well-being. Which of the following would be the best explanation for the purpose of open visiting hours? Select all that apply.

Correct Answer: B

Rationale: The correct answer is B: To strengthen the relationship between the family and health care provider. Rationale: 1. Open visiting hours encourage family involvement in care, fostering a partnership between healthcare providers and families. 2. Family support can positively impact patient outcomes and satisfaction. 3. It allows families to be updated on the patient's condition and involved in decision-making. 4. Strengthening the relationship can lead to better communication and trust between all parties. Summary of Incorrect Choices: A: Open visiting hours may disrupt rest and quiet, but the primary purpose is not to provide rest. C: Open visiting hours do not aim to control the number of visitors but rather encourage family involvement. D: While open visiting hours may not provide an entirely undisturbed environment, the focus is on improving family-provider relationships.

Question 5 of 5

A Muslim woman is admitted to the ICU after suffering severe burns over most of her body. Which of the following would be the most appropriate measure for the nurse, a woman, to take in respect for the cultural practices of this patient?

Correct Answer: D

Rationale: The correct answer is D because it demonstrates respect for the patient's autonomy and individual preferences. By asking the patient's husband about religious and cultural preferences, the nurse acknowledges the importance of involving the family in decision-making and shows sensitivity to the patient's beliefs. This approach promotes cultural competence and patient-centered care. Choice A is incorrect because insisting on a female doctor may not align with the patient's preferences and may limit the available medical staff. Choice B is also incorrect as dietary restrictions are not necessarily the most pressing issue in this scenario. Choice C is incorrect as it assumes a cultural practice without verifying the patient's specific preferences and may not be necessary or appropriate in this context.

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