A nurse is caring for a 24-year-old female client who was admitted to the emergency unit following a horseback riding accident.
Increase the propofol infusion
Assess the client's pain
Notify the social worker the client is awake
Have the client sign consent forms for procedures already performed
Consider extubating the client
Determine the client’s decision-making ability
Decrease the noise and light stimuli in the room as much as possible
Explain all procedures
Correct Answer : B,F,G,H
Choice B rationale: Assessing the client's pain is crucial as the client becomes more aware. Pain management is essential for comfort and recovery. As the client wakes up, they may begin to experience pain and discomfort, which should be promptly addressed.
Choice F rationale: Determining the client’s decision-making ability is important as the client wakes up to assess their cognitive status and ability to participate in their own care decisions. This helps in planning further care and interventions appropriately.
Choice G rationale: Decreasing the noise and light stimuli in the room as much as possible helps to create a calm environment, which is important for a patient recovering from trauma and surgery. It helps reduce anxiety and agitation as the client becomes more aware of their surroundings.
Choice H rationale: Explaining all procedures is essential for the client’s understanding and cooperation. Clear communication helps reduce anxiety and ensures that the client knows what to expect, which is important for their overall comfort and trust in the healthcare team.
Choice A rationale: Increasing the propofol infusion is incorrect because it is necessary to assess the client’s awareness and response to the current sedation level. Over-sedating the client can delay recovery and obscure their neurological status.
Choice C rationale: Notifying the social worker the client is awake is not immediately necessary at this stage. The focus should be on the client's medical and physical condition first.
Choice D rationale: Having the client sign consent forms for procedures already performed is inappropriate because the client may not be in a suitable mental state to provide informed consent due to recent sedation and trauma.
Choice E rationale: Considering extubating the client is premature. The decision to extubate should be based on a thorough assessment of the client’s readiness, including their ability to maintain their airway and adequate ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"C"}
Explanation
Rationale for correct answer:
- Pain relief: The purpose of epidural anesthesia is to provide pain relief during labor. Since the nurse’s notes state that the client is comfortable and reports adequate pain relief, it demonstrates that the epidural anesthesia is effective.
- Fetal heart rate: Monitoring fetal heart rate is crucial to ensure the well-being of the baby during labor. The nurse’s notes state that the fetal heart rate is within normal limits, indicating that the epidural anesthesia has not adversely affected the baby and is working effectively.
Rationale for incorrect answers:
- Good urine output: While good urine output is important, it is not a direct indicator of the effectiveness of epidural anesthesia. It does not provide information about pain relief or fetal well-being.
- Vital signs: Vital signs are important to monitor but do not specifically indicate the effectiveness of epidural anesthesia in terms of pain relief and fetal well-being.
- Progression of labor: The progression of labor is influenced by various factors, not just the effectiveness of epidural anesthesia. It is not a direct measure of the epidural’s effectiveness.
- Labor augmentation: Labor augmentation refers to interventions to stimulate labor. It is not related to the effectiveness of epidural anesthesia.
Correct Answer is ["B","E","F","G"]
Explanation
Choice A rationale
Short-term memory loss is not typically associated with elder mistreatment. It may result from normal aging, neurological conditions like Alzheimer's disease, or other medical issues affecting cognitive function. It does not directly indicate mistreatment.
Choice B rationale
Malnutrition in the elderly can be a sign of neglect or mistreatment, where the individual may not receive adequate nutrition due to inadequate caregiving or intentional withholding of food. It can lead to severe health complications and indicates a lack of proper care.
Choice C rationale
Bilateral leg edema can result from various medical conditions, such as heart failure, chronic venous insufficiency, or renal disease. It is not a specific indicator of elder mistreatment and requires a thorough medical evaluation to determine the underlying cause.
Choice D rationale
Diminished breath sounds are typically related to respiratory conditions, such as pneumonia, chronic obstructive pulmonary disease (COPD), or pleural effusion. While they require medical attention, they do not directly indicate elder mistreatment.
Choice E rationale
Dark room lighting can suggest poor living conditions and inadequate care, potentially indicating neglect or mistreatment. Proper lighting is essential for the safety and well-being of elderly individuals, and its absence may reflect a lack of proper care and attention.
Choice F rationale
Poor hygiene is a common sign of neglect in elder mistreatment cases. It indicates that the individual may not receive assistance with personal care, leading to physical and emotional distress. Neglecting hygiene needs can result in infections and other health issues.
Choice G rationale
Pressure injuries, or bedsores, are often a result of prolonged immobility and inadequate repositioning, which can occur in cases of elder mistreatment or neglect. These injuries can lead to severe complications and are indicative of a lack of proper care and attention to the individual's needs.
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