A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply)

Suction the ET to remove secretions.

Verify the placement of the ET.

Check for kinks in the ventilator tubing.

Administer a bronchodilator.

Increase the tidal volume.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason: Suctioning the ET removes secretions obstructing airflow, increasing peak airway pressure. Mucus buildup narrows the airway, triggering alarms. Clearing secretions restores patency, reduces pressure, and prevents complications like atelectasis or hypoxia, critical for effective ventilation in mechanically ventilated clients.
Choice B reason: Verifying ET placement ensures the tube is in the trachea. Misplacement, like esophageal intubation, increases airway resistance, elevating peak pressure. Confirmation via capnography or X-ray prevents hypoxia, ensuring proper ventilation and safety in clients on mechanical ventilators.
Choice C reason: Checking for kinks in ventilator tubing addresses mechanical obstructions raising peak airway pressure. Kinks restrict airflow, triggering alarms. Straightening tubing restores normal gas delivery, reducing resistance and maintaining effective ventilation, preventing hypoxia in mechanically ventilated clients.
Choice D reason: Administering a bronchodilator relieves bronchospasm, a common cause of high peak airway pressure. Bronchoconstriction narrows airways, increasing resistance. Bronchodilators relax smooth muscles, improving airflow and reducing pressure, addressing reversible causes like asthma in ventilated clients.
Choice E reason: Increasing tidal volume exacerbates high peak airway pressure, risking barotrauma or lung injury by forcing air against resistance. Addressing underlying causes like secretions or bronchospasm is safer, as higher volumes do not resolve the root issue, potentially worsening outcomes.

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Correct Answer is A

Explanation

Choice A reason: Increased energy and motivation signal improvement in major depressive disorder, countering fatigue and anhedonia. Serotonin and norepinephrine rebalance, often from treatment, restores drive and engagement, reflecting neurochemical stabilization in the brain’s limbic system, critical for mood regulation and recovery.
Choice B reason: Self-doubt in decision-making reflects persistent depressive symptoms, like low self-esteem and cognitive impairment. Negative thought patterns, driven by altered prefrontal cortex activity, indicate ongoing depression, not improvement, requiring adjusted interventions to address these neurocognitive deficits in major depressive disorder.
Choice C reason: Sleeping 12 hours daily indicates hypersomnia, a depressive symptom, suggesting no improvement. Disrupted circadian rhythms and serotonin dysregulation cause excessive sleep, contrasting with recovery signs like normalized sleep patterns. This reflects persistent neurochemical imbalances hindering mood stabilization in depression.
Choice D reason: Social isolation is a core depressive symptom, driven by anhedonia and low mood, indicating no improvement. Withdrawal reflects ongoing dopamine and serotonin imbalances, preventing social engagement. Recovery involves increased interaction, making isolation a sign of persistent major depressive disorder.

A. A client who describes having persistent feelings of anger about the hurricane. B. A client who expresses a realization that life will not return to the way it was before the hurricane. C. A client who moved to an apartment located on higher ground than her previous home. D. A client who has frequent nightmares about the hurricane. E. A client who describes feeling disconnected from those around him following the hurricane.

Correct Answer is ["A","D","E"]

Explanation

Choice A reason: Persistent anger about the hurricane is a PTSD symptom, reflecting emotional dysregulation and hyperarousal post-trauma. This ongoing distress, per DSM-5 criteria, warrants referral for mental health evaluation to address potential PTSD, making it a correct indicator for intervention.
Choice B reason: Realizing life will not return to normal is a realistic adjustment, not necessarily a PTSD symptom. Without additional distress indicators, this does not meet diagnostic criteria for PTSD, making it incorrect for requiring a referral in this context.
Choice C reason: Moving to higher ground is a practical response to reduce future risk, not a PTSD symptom. It reflects adaptive coping rather than psychological distress, so it does not warrant a referral for PTSD assessment, making it incorrect.
Choice D reason: Frequent nightmares about the hurricane are a hallmark PTSD symptom, classified as intrusive re-experiencing per DSM-5. This significant distress disrupts sleep and daily functioning, necessitating a referral for mental health evaluation, making it a correct choice.
Choice E reason: Feeling disconnected from others indicates emotional numbing, a PTSD avoidance symptom per DSM-5. This social withdrawal post-hurricane suggests significant psychological impact, warranting a referral for PTSD assessment to address underlying trauma, making it correct.

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A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has major depressive disorder. Which of the following findings should indicate to the nurse that the client’s condition is improving?

Correct Answer is A

Explanation

A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For which of the following clients should the nurse initiate a referral to assess for the presence of post-traumatic stress disorder? (Select all that apply)

Correct Answer is ["A","D","E"]

Explanation

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