The nurse is using presence to reduce the anxiety of a critically ill patient. What nursing behavior demonstrates an effective use of presence?

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Question 1 of 5

The nurse is using presence to reduce the anxiety of a critically ill patient. What nursing behavior demonstrates an effective use of presence?

Correct Answer: C

Rationale: The correct answer is C because maintaining eye contact with the patient during explanations is a non-verbal way to show attentiveness and empathy, which can help reduce the patient's anxiety. This behavior demonstrates active listening and engagement, making the patient feel heard and understood. A: Staying in the patient's room to complete documentation is not an effective use of presence as it does not involve direct interaction with the patient. B: Having a conversation in the patient's room that excludes the patient is also not an effective use of presence as it does not involve engaging with the patient. D: Focusing on specific nursing care tasks while in the patient's room, although important, may not necessarily demonstrate presence in reducing the patient's anxiety.

Question 2 of 5

The sister of a patient in the ICU has been at the patients bedside non-stop for 48 hours. The nurse suggests to her that she return home to rest. Which of the following is the proper rationale for the nurse making such a suggestion?

Correct Answer: D

Rationale: The correct answer is D: The sister needs to maintain her own health during this time. It is essential for the sister to take care of her own health and well-being to be able to provide the best support to the patient. Continuous stress and lack of rest can negatively impact her ability to support the patient effectively. Encouraging her to rest will ensure she remains physically and mentally well to continue supporting the patient in the long run. Incorrect Choices: A: The sister is in the way of the health care providers - This is incorrect as the primary concern is the well-being of the sister and her ability to provide support. B: The patient may become annoyed by her continual presence - This is not the main reason for suggesting the sister to rest, as the focus is on her own health. C: The patient will recover more easily in peace and quiet - While peace and quiet can be beneficial for the patient, the main focus here is on the sister's well-being.

Question 3 of 5

The nurse is caring for a very seriously ill patient in the CCU. The family visits sporadically, stays for only a short time, and does not ask many questions. How could the nurse best begin to involve the family in the patients care?

Correct Answer: D

Rationale: The correct answer is D: Ask the family to complete the Critical Care Family Needs Inventory. This tool helps assess the family's needs and concerns, enabling the nurse to tailor care accordingly. By understanding the family's specific needs, the nurse can provide appropriate support and information, fostering better involvement and understanding. A: Asking one family member to assist with the patient's bath may not address the overall family's needs or involvement in care. B: Encouraging family members to stay longer does not necessarily address their specific needs or facilitate effective communication. C: Focusing solely on the legal next of kin may exclude important family members who also need support and involvement in the patient's care.

Question 4 of 5

A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care?

Correct Answer: B

Rationale: The correct answer is B: Cluster nursing activities so that the patient has uninterrupted rest periods. Rationale: 1. Clustering nursing activities allows for uninterrupted rest periods, essential for improving sleep quality and addressing disturbed sensory perception. 2. Administering sedatives or opioids (Option A) can lead to drug dependence, tolerance, and adverse effects in older adults. 3. Silencing alarms (Option C) compromises patient safety by impeding timely monitoring and response to critical events. 4. Eliminating assessments (Option D) between 0100 and 0600 disregards the necessity of monitoring vital signs and assessing patient condition around the clock.

Question 5 of 5

When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most important information for the nurse to obtain is:

Correct Answer: D

Rationale: The correct answer is D: Pulmonary artery wedge pressure (PAWP). This is crucial in monitoring a patient with a large anterior wall myocardial infarction as it provides information on left ventricular function and fluid status. A high PAWP may indicate left ventricular failure or fluid overload, requiring immediate intervention. A: Central venous pressure (CVP) is not as specific for assessing left ventricular function and may not provide accurate information in this scenario. B: Systemic vascular resistance (SVR) is important in assessing systemic blood flow, but it may not directly indicate left ventricular function in this case. C: Pulmonary vascular resistance (PVR) is more relevant in conditions affecting the pulmonary circulation and may not be as immediately informative in assessing left ventricular function in this context.

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