Priority Decision: A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first in the patient?

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Hypoxemia. When a patient in the PACU exhibits emergence delirium with agitation and thrashing, the nurse's first priority should be to assess for hypoxemia. Hypoxemia can lead to altered mental status, including delirium, so addressing this issue is crucial to ensure the patient's safety and well-being. The nurse should assess the patient's oxygen saturation levels, respiratory rate, and lung sounds to determine if there is any impairment in oxygenation. Option B) Neurologic injury is not the most immediate concern in this situation. While neurologic injury is always a potential risk in any patient, the patient's current symptoms are more indicative of hypoxemia rather than neurologic injury. Option C) Distended bladder and option D) Cardiac dysrhythmias are also important considerations in postoperative patients, but they are not the priority in a patient presenting with emergence delirium and agitation. These issues can be assessed once the patient's oxygenation status has been addressed. In an educational context, this question highlights the importance of prioritizing patient assessments based on the presenting symptoms and potential complications. It emphasizes the need for nurses to quickly identify and address critical issues to ensure patient safety and optimal outcomes. Understanding the rationale behind prioritizing assessments can help nurses make informed clinical decisions in fast-paced and high-stress environments like the PACU.

Correct Answer: C

Rationale: In this scenario, option C, "I don't drink fluids after 4 P.M.," indicates that Mr. K. needs further health teaching regarding measures to relieve or prevent constipation. Proper hydration is essential for maintaining bowel regularity, and limiting fluids in the evening can contribute to constipation. Option A, "I eat whole-wheat bread with my meals," and option B, "I eat fruit three times a day," are both appropriate strategies to prevent constipation as they provide dietary fiber which aids in digestion and bowel movements. Option D, "I don't like to take enemas," is not directly related to preventive measures for constipation. Enemas are typically used as a last resort for severe constipation and are not a primary method for managing bowel regularity. From an educational perspective, this question highlights the importance of holistic patient education during the rehabilitative phase post-cerebrovascular accident. Nurses must ensure that patients receive comprehensive instructions on managing various aspects of their health, including strategies to prevent constipation to promote overall well-being and recovery.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Pilocarpine. Pilocarpine is a parasympathomimetic drug that acts on the muscarinic receptors in the eye, causing constriction of the pupil (miosis). This medication is commonly used to treat conditions like glaucoma by reducing intraocular pressure. Option A) Epinephrine (Adrenalin) is a sympathomimetic drug that acts on alpha and beta adrenergic receptors, causing dilation of the pupil (mydriasis) rather than constriction. Option B) Acetazolamide (Diamox) is a carbonic anhydrase inhibitor used to decrease intraocular pressure in glaucoma but does not directly affect pupil size. Option C) Atropine is an anticholinergic drug that blocks muscarinic receptors, leading to pupil dilation (mydriasis) rather than constriction. Educationally, understanding the pharmacological actions of different drugs on the eye is crucial for nurses to provide safe and effective care to patients with eye conditions. Knowing the specific effects of medications like pilocarpine can help nurses monitor for intended therapeutic outcomes and potential side effects related to pupillary changes.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) has difficulty seeing objects that are very close because her lens is less elastic. Presbyopia is a common age-related condition where the lens of the eye loses its elasticity, making it harder to focus on close objects. This is why Mrs. Williams is experiencing difficulty with near vision. Option A is incorrect because presbyopia affects near vision, not distance vision. Option B is incorrect because nearsightedness (myopia) is the opposite of presbyopia. Option C is incorrect as presbyopia is not caused by a curvature in the eye but rather by the loss of lens elasticity. In an educational context, it is crucial for healthcare professionals to understand common age-related conditions like presbyopia to provide appropriate care and advice to patients. By knowing the correct symptoms and characteristics of presbyopia, healthcare providers can offer effective treatment options and help patients manage their vision changes as they age.

Correct Answer: B

Rationale: The best response to the patient who completed detoxing from heroin and feels misunderstood by family members is option B: "Ask your family members if they ever had the flu. Tell them that withdrawal is like having the worst flu they ever had." This response is the most appropriate because it uses a relatable analogy to help family members understand the intensity and discomfort of withdrawal symptoms. By comparing withdrawal to a severe flu, it helps bridge the gap in understanding between the patient and their family. Option A is incorrect because suggesting Alcoholics Anonymous may not directly address the patient's concern about their family's lack of understanding. Option C is incorrect as comparing withdrawal to going on a diet trivializes the physical and psychological struggles associated with withdrawal. Option D is highly inappropriate and dangerous advice as it encourages the patient to use heroin, which contradicts the goal of recovery and sobriety. In an educational context, it's crucial for healthcare providers to communicate effectively with patients and their families to facilitate understanding and support. Using analogies that are relatable and easy to comprehend can help bridge communication gaps and foster empathy and support for individuals recovering from substance abuse. Educating patients and their families about the challenges of withdrawal can promote a more supportive and understanding environment essential for successful recovery.