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Critical Care Nursing NCLEX Questions Questions

Question 1 of 5

The nurse is assessing the critically ill patient for delirium . The nurse recognizes which characteristics that indicate hyperactive delirium? (Select aabllir bt.hcaomt /atepstp ly.)

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.

Question 2 of 5

In assessing a patient, the nurse understands that what sym ptomology is an early sign of hypoxemia?

Correct Answer: D

Rationale: Step 1: Restlessness is an early sign of hypoxemia due to the body's response to low oxygen levels. Step 2: Restlessness occurs as the body tries to increase oxygen intake. Step 3: Other choices are incorrect because clubbing and cyanosis are late signs, while hypotension is not a specific early sign of hypoxemia.

Question 3 of 5

As part of the admission process, the nurse asks several questions about family relationships. The nurse bases these actions on which rationale?

Correct Answer: A

Rationale: Step-by-step rationale for why choice A is correct: 1. Involving the family in patient care is crucial for holistic care. 2. Assessing family relationships helps identify support systems and potential conflicts. 3. Understanding family dynamics aids in creating a comprehensive care plan. 4. Family involvement can enhance patient outcomes and satisfaction. Summary of incorrect choices: B. Irrelevant, as the focus is on patient-centered care, not just fulfilling an assessment tool. C. Personal curiosity is not a valid reason for assessing family relationships in healthcare. D. Conducting research on family patterns does not directly impact the immediate care of the patient.

Question 4 of 5

A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor?

Correct Answer: B

Rationale: The correct answer is B: Liver. The nurse should monitor liver function in this client because acetaminophen is primarily metabolized in the liver. Alcohol abuse can also contribute to liver damage, increasing the risk of liver toxicity from acetaminophen. Monitoring liver function tests like AST, ALT, and bilirubin levels can help detect any liver damage early. Choice A, cardiorespiratory, is not directly related to acetaminophen or alcohol abuse in this scenario. Choice C, sensory, is not relevant to monitoring organ function in this context. Choice D, kidney, is not the primary concern because acetaminophen is mainly metabolized in the liver, and kidney function is not typically affected by acetaminophen use.

Question 5 of 5

The nurse is caring for a critically ill patient who can speak. The nurse notices that the patient is demonstrating behaviors indicative of anxiety but is silent. What nursing strategy would give the nurse the most information about the patients feelings?

Correct Answer: B

Rationale: The correct answer is B because asking the patient to share his or her internal dialogue can provide direct insight into the patient's thoughts and feelings, allowing the nurse to address specific anxieties. This approach promotes open communication and understanding. Choice A focuses on providing information but may not directly address the patient's feelings. Choice C is unrelated to addressing the patient's anxiety. Choice D addresses pain control, which is important but not directly related to exploring the patient's emotions. Therefore, option B is the most effective strategy for gaining insight into the patient's feelings in this scenario.

Similar Questions

The nurse is caring for a critically ill patient who can speak. The nurse notices that the patient is demonstrating behaviors indicative of anxiety but is silent. What nursing strategy would give the nurse the most information about the patients feelings?
The American Association of Critical-Care Nurses (AACN) sponsors certification in critical care nursing for several critical care subspecialties. What is the most important benefit of such certification for the profession of nursing?
The nurse uses the Situation-Background-Assessment-Recommendation (SBAR) format to communicate a change in patient status to a healthcare provider. In which order should the nurse make the following statements?
A nurse who plans care based on the patient’s gender, ethn ai bc iri bt .y co, ms /p tei sr ti tuality, and lifestyle is said to demonstrate what focus?
The son of a dying patient tells the nurse, 'Mother doesn’t respond anymore when I visit. I don’t think she knows that I am here.' Which response by the nurse is appropriate?

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