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.

Correct Answer: C

Rationale: The correct answer is C: Cardiac output (CO) of 5 L/min. In cardiogenic shock, the primary goal of using an IABP is to improve cardiac output to ensure adequate perfusion to vital organs. A cardiac output of 5 L/min indicates adequate blood flow and perfusion. Choice A is incorrect as urine output is not a direct indicator of cardiac function. Choice B is incorrect as a heart rate of 110 beats/minute alone does not provide information on the effectiveness of the IABP in improving cardiac output. Choice D is incorrect as stroke volume alone does not provide a comprehensive assessment of overall cardiac function.

Correct Answer: C

Rationale: The correct answer is C: Rhinorrhoea or otorrhoea with Halo sign. This finding is consistent with a basilar skull fracture because it indicates a cerebrospinal fluid (CSF) leak from the skull base. The Halo sign refers to a ring of CSF surrounded by blood, which can be seen on a white absorbent pad. This specific sign is a classic indicator of a basilar skull fracture, as the CSF leakage from the ears or nose can be tinged with blood due to the fracture disrupting nearby blood vessels. For the other choices: A: Hematemesis and abdominal distention are not typical manifestations of a basilar skull fracture. They are more indicative of gastrointestinal issues or internal bleeding. B: Asymmetry of the face and eye movements can be seen with facial nerve or orbital injuries, but it is not specific to a basilar skull fracture. D: Abnormal position and movement of the arm are not directly related to a

Correct Answer: B

Rationale: The correct answer is B because it shows understanding that the PAC helps in managing fluid therapy effectively. The PAC measures pressures in the heart and lungs, guiding fluid management. Choice A is incorrect as the PAC is not primarily for IV fluid administration. Choice C shows understanding of the catheter placement but not its purpose. Choice D is incorrect as the PAC is not for the heart to heal but to monitor cardiac status.

Correct Answer: A

Rationale: The presence of an endotracheal tube can predispose the client to increased pain and anxiety due to discomfort, difficulty breathing, and potential for aspiration. The tube insertion process itself can be painful and traumatic. Frequent vital sign assessment, monitor alarms, and room temperature are not directly associated with increased pain and anxiety from the endotracheal tube.

Correct Answer: C

Rationale: The correct answer is C: Paralysis. Neuromuscular blocking agents work by blocking the transmission of nerve impulses at the neuromuscular junction, leading to muscle paralysis. This paralysis helps facilitate intubation, surgical procedures, and mechanical ventilation. A: Analgesia - Neuromuscular blocking agents do not provide pain relief; they primarily induce muscle paralysis without affecting pain sensation. B: Anticonvulsant - Neuromuscular blocking agents do not prevent or treat seizures; their mechanism of action is not related to controlling convulsions. D: Sedation - Neuromuscular blocking agents do not induce sedation; they specifically target the neuromuscular junction to cause muscle paralysis.

Correct Answer: B

Rationale: The correct answer is B: Encouraging family members to make notes of questions they have for the physician during family rounds. This strategy helps families cope with the stress of critical illness by empowering them to stay informed and actively participate in the patient's care. By encouraging them to make notes, it promotes effective communication with the healthcare team and ensures that their concerns and questions are addressed promptly. Other choices are incorrect: A: Asking the family to leave during the morning bath to promote the patient’s privacy is not a helpful strategy for coping with stress as it may lead to feelings of isolation and lack of involvement in the patient's care. C: Providing continuity of nursing care is important but may not directly address the family's coping mechanisms during a critical illness. D: Providing a daily update of the patient’s condition to the family spokesperson is valuable but may not fully address the family's need for active participation and communication with the healthcare team.

Correct Answer: B

Rationale: The correct answer is B: Administer a prescribed PRN opioid analgesic. This is the priority intervention because severe breakthrough pain requires immediate relief, and opioids are the most effective for managing severe pain in terminally ill patients. Warm compresses (A) may provide some comfort but do not address the underlying pain. Reassessing pain after 2 hours (C) delays necessary relief. Distraction techniques (D) are not appropriate for severe breakthrough pain as they do not directly address the pain itself. Administering the prescribed opioid analgesic promptly is crucial for providing timely and effective pain management in this situation.

Correct Answer: D

Rationale: The correct answer is D because the presence of red blood cells and albumin in the urine indicates possible kidney damage from the blunt trauma. This is concerning as it may suggest renal injury or dysfunction. A: Creatinine levels in the urine being similar to blood levels is normal as creatinine is filtered by the kidneys. B: Sodium and chloride being present in the urine is expected as they are components of urine. C: Urine uric acid levels matching serum levels is common as uric acid is excreted by the kidneys. In summary, the presence of red blood cells and albumin in the urine is abnormal and indicates potential kidney damage, making it the correct answer.