The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle crash. The patient’s Glasgow Coma Score is 3 anda binirbte.cromm/ittetset ntly withdraws when painful stimuli are introduced. The patient is ventilator dependent and occasionally takes a spontaneous breath. The primary care provider explains to the family that the patient has severe neurological impairment and it is not expected that the patient will ever recover consciousness. What concept does this situation depict?

Correct Answer: C

Rationale: The correct answer is C: A persistent vegetative state. This choice is correct because the patient exhibits minimal responsiveness, only withdrawing to painful stimuli, and lacks meaningful interaction or consciousness. A persistent vegetative state is characterized by preserved wakefulness without awareness, which aligns with the patient's condition. Choice A: An organ donor is incorrect because the patient's neurological impairment does not necessarily indicate readiness for organ donation. Choice B: Brain death is incorrect because the patient still exhibits some reflexive responses, indicating a level of brain function beyond brain death. Choice D: Terminally ill is incorrect as it does not specifically address the patient's neurological status and prognosis, which is better described by a persistent vegetative state.

Correct Answer: C

Rationale: The correct answer is C: administer intravenous sodium bicarbonate. In this case, the patient has metabolic acidosis with a low pH and low bicarbonate levels. Administering sodium bicarbonate can help correct the acidosis by increasing the bicarbonate levels and improving the pH. This treatment is essential to address the underlying metabolic imbalance. Choice A is incorrect because administering morphine would not address the root cause of the acidosis and could potentially worsen the respiratory status. Choice B is incorrect as intubation and mechanical ventilation are not indicated solely based on the acid-base imbalance. Choice D is also incorrect as canceling the dialysis session would not address the metabolic acidosis and could potentially worsen the patient's condition.

Correct Answer: B

Rationale: Rationale for Correct Answer (B - Brain death determination is required before organs can be retrieved for transplant): 1. Brain death determination is a medical necessity to ensure the organs are viable for transplant. 2. Organs must be retrieved promptly after brain death to maintain their functionality. 3. Brain death criteria ensure that the donor is truly deceased before organ retrieval. Summary of Why Other Choices are Incorrect: A: While discussing organ donation is important, comfort level is not the main factor in organ shortage awareness. C: Donation after cardiac death is ethically acceptable, but it is not directly related to the need for brain death determination. D: Withdrawing life support solely to become an organ donor is ethically questionable and not a necessary step in organ donation.

Correct Answer: A

Rationale: The correct answer is A because evaluating morning lab results is crucial to monitor the patient's condition before dialysis. Abnormal results may impact the dialysis treatment plan. Option B is incorrect as administering antihypertensive medications is not directly related to dialysis. Option C is incorrect as assessing the dialysis access site is the responsibility of the dialysis team. Option D is incorrect as weighing the patient is not typically done immediately before dialysis.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates effective handoff communication by involving key stakeholders (nephrology consultant physician), requesting specific patient updates, and collaborating on patient care tasks (placing a central line). This scenario promotes continuity of care and ensures important information is shared. Explanation for why other choices are incorrect: B: High noise level disrupts communication and can lead to errors or omissions in handoff information. C: While using a standardized checklist can be beneficial, it alone does not guarantee effective communication if not utilized properly or if key information is missed. D: Conducting reports at the patient's bedside is beneficial for patient involvement but may not address the need for involving relevant healthcare providers like the consultant physician in the handoff process.

Correct Answer: C

Rationale: The correct answer is C because inquiring about specific cultural rituals and preferences shows respect for the patient's cultural beliefs and values. By asking about these aspects, the nurse can provide care that aligns with the patient's cultural background, promoting comfort and understanding. This action also demonstrates a commitment to individualized care. Choice A is incorrect because standardized care may not always be culturally appropriate. Choice B is incorrect as avoiding discussions about death can hinder effective communication and support. Choice D is incorrect as advising families to strictly follow hospital guidelines may overlook the importance of cultural considerations in end-of-life care.

Correct Answer: C

Rationale: The correct answer is C: Tachycardia. Hypoxemia results in decreased oxygen levels in the blood, stimulating the body to increase heart rate to improve oxygen delivery. Tachycardia is an early sign of the cardiovascular system compensating for hypoxemia. Heart block (A) is a disruption in the electrical conduction within the heart and is not directly related to hypoxemia. Restlessness (B) is a non-specific sign and can be caused by various factors. Tachypnea (D) is an increased respiratory rate, which is a response to hypoxemia but not a direct effect on the cardiovascular system.

Correct Answer: D

Rationale: The correct answer is D because initiating the alcohol withdrawal protocol shows an understanding of managing a patient at risk for alcohol withdrawal syndrome. This protocol involves carefully monitoring the patient's symptoms, providing appropriate medications, and ensuring a safe environment. Option A is incorrect as it downplays the seriousness of alcohol withdrawal. Option B is incorrect as there are assessment tools available for identifying alcohol withdrawal. Option C is incorrect as pain management should be tailored to the individual's needs, not necessarily lessened due to alcohol withdrawal risk.

Correct Answer: C

Rationale: The correct answer is C because palliative care is not just for the dying but also for those with serious illnesses. A: Correct - basic nursing care is essential in palliative care. B: Correct - common symptoms in palliative care include nausea, agitation, and sleep disturbance. D: Correct - palliative care aims to relieve symptoms and improve quality of life. Choice C is incorrect as it wrongly implies palliative care is only for the dying, which is a misconception.