The assessment of pain and anxiety is a continuous proces s. When critically ill patients exhibit signs of anxiety, what is the nurse’s first priority?

Correct Answer: C

Rationale: The correct answer is C: To identify and treat the underlying cause. The first priority of the nurse when critically ill patients exhibit signs of anxiety is to determine the root cause of the anxiety. By identifying and addressing the underlying cause, the nurse can effectively manage the patient's anxiety and prevent further complications. Administering medications without understanding the cause can mask the symptoms and lead to ineffective treatment. Reassessing the patient hourly may not address the root cause and could delay appropriate intervention. Pain medication may not be necessary if the anxiety is not related to pain. Treating the underlying cause ensures holistic and effective care for the patient.

Correct Answer: C

Rationale: The correct answer is C, the 86-year-old postoperative from colonic resection. This patient is at the greatest risk for delirium due to being elderly, having undergone surgery, and having a history of being from a nursing home. These factors contribute to an increased susceptibility to delirium. A: The 36-year-old with alcohol withdrawal may be at risk for delirium tremens, but the older age of the patient in choice C places them at higher risk. B: The 54-year-old with an elevated creatinine level postoperative is at risk for complications, but age and history of nursing home placement increase the risk for delirium in choice C. D: The 95-year-old with community-acquired pneumonia is at risk for delirium, but the combination of age, surgery, and nursing home history in choice C presents a greater risk.

Correct Answer: B

Rationale: The correct answer is B: Art therapy. Art therapy can help critically ill patients express emotions, reduce anxiety, and cope with pain in a nonverbal way. It provides a creative outlet for self-expression and can improve overall well-being. Anaerobic exercise (A) may not be suitable for critically ill patients due to physical limitations. Guided imagery (C) may not be effective for all patients and requires a certain level of cognitive ability. Music therapy (D) can be beneficial, but art therapy is specifically known for its effectiveness in addressing emotional and psychological needs in critically ill patients.

Correct Answer: A

Rationale: The correct answer is A because pain and anxiety trigger the sympathetic nervous system's fight-or-flight response, increasing heart rate, blood pressure, and stress hormones to prepare the body for potential danger. This physiological response helps the individual respond to perceived threats. Choices B, C, and D are incorrect because pain and anxiety typically increase stress levels, do not necessarily remove one from harm, and can hinder rather than enhance performance due to distraction and decreased focus.

Correct Answer: A

Rationale: The correct answer is A: Agitation. In hyperactive delirium, patients often exhibit restlessness, agitation, and hyperactivity. This behavior is a key characteristic indicating hyperactive delirium. Apathy (B), biting (C), and hitting (D) are not typically associated with hyperactive delirium. Apathy may be seen in hypoactive delirium, while biting and hitting are not specific indicators of delirium subtypes. Therefore, the correct choice is A as it aligns with the typical presentation of hyperactive delirium.