A nurse is providing care to a client who has spent several weeks in the intensive care unit because of complications related to shock. What adverse psychological outcomes should the nurse educate the client about prior to transfer to the medical unit?

Hypoxia and acidosis

Hearing deficits and increased risk of glaucoma

Bipolar behaviors and schizotypal behaviors

Disorientation and depression

Answer and Explanation

The Correct Answer is D

A) Hypoxia and acidosis While hypoxia and acidosis are serious complications of shock, they are physiological rather than psychological outcomes. These conditions primarily affect the body's metabolic and respiratory functions, rather than mental health or behavior.

B) Hearing deficits and increased risk of glaucoma Hearing deficits and increased risk of glaucoma are potential complications associated with certain medical conditions or medications but are not directly related to the psychological outcomes of shock. These conditions affect sensory perception (hearing and vision) rather than mental health or behavior.

C) Bipolar behaviors and schizotypal behaviors Bipolar behaviors and schizotypal behaviors are manifestations of mood and psychotic disorders, respectively, and are not typical adverse outcomes of shock. While psychological disturbances can occur in critically ill patients, they are not commonly characterized by specific psychiatric diagnoses like bipolar or schizotypal behaviors.

D) Disorientation and depression Disorientation and depression are common adverse psychological outcomes experienced by patients who have spent an extended period in the intensive care unit (ICU) due to complications related to shock. Prolonged ICU stays, medical interventions, sedation, and physical discomfort can contribute to feelings of confusion, disorientation, and depression in patients. Therefore, it is essential for the nurse to educate the client about these potential psychological effects and provide appropriate support and resources to address them during the transition to the medical unit.

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Correct Answer is A

Explanation

Answer: A. Ensuring that the client and their family are kept informed about the client's care

Rationale:

A. Ensuring that the client and their family are kept informed about the client's care:
This action is the priority because communication is vital in managing a client with multiple organ dysfunction syndrome (MODS). Keeping the client and their family informed can help them understand the seriousness of the condition, the plan of care, and potential outcomes. It also fosters trust and ensures that the family can make informed decisions regarding the client's care.

B. Being aware of the client's wishes regarding care:
While being aware of the client’s wishes is important, especially in critical conditions like MODS, the priority lies in ensuring ongoing communication about the client's current status and treatment. Understanding the client's wishes can guide care but should follow the immediate need for clear communication about the evolving situation.

C. Scheduling periods of rest for the client:
Rest is essential for recovery, particularly in clients with MODS, but scheduling rest periods is a part of implementing care rather than a primary action. It can be planned based on the client’s needs and condition but does not take precedence over ensuring that the family is informed.

D. Discussing the client's resting times with the family:
While involving the family in discussions about the client's care is beneficial, the immediate priority is to ensure they are fully informed about the overall condition and care plan. This discussion can occur after establishing a solid communication foundation regarding the client's status and care approach.

A. "Endolymph fluid provides protection to the structures of the inner ear." B. "Aqueous humor provides protection to the structures of the inner ear." C. "Vitreous humor provides protection to the structures of the inner ear." D. "Sanguineous fluid provides protection to the structures of the inner ear."

Correct Answer is A

Explanation

A. "Endolymph fluid provides protection to the structures of the inner ear": Endolymph is a fluid found within the membranous labyrinth of the inner ear. It plays a crucial role in maintaining the balance of ions necessary for proper sensory function of the auditory and vestibular systems. Endolymph helps protect the delicate sensory structures of the inner ear, including the hair cells responsible for hearing and balance.

B. "Aqueous humor provides protection to the structures of the inner ear": Aqueous humor is a clear fluid that fills the anterior chamber of the eye, maintaining intraocular pressure and nourishing the cornea and lens. It is not involved in protecting the structures of the inner ear.

C. "Vitreous humor provides protection to the structures of the inner ear": Vitreous humor is a gel-like substance that fills the posterior chamber of the eye, providing structural support to the eyeball and maintaining its shape. It is not associated with protecting the structures of the inner ear.

D. "Sanguineous fluid provides protection to the structures of the inner ear": Sanguineous fluid refers to blood or a blood-like fluid, which does not directly provide protection to the structures of the inner ear. While the circulatory system supplies oxygen and nutrients to the inner ear structures, blood itself does not serve as a protective fluid within the inner ear.

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A nurse is providing care to a client who has spent several weeks in the intensive care unit because of complications related to shock. What adverse psychological outcomes should the nurse educate the client about prior to transfer to the medical unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who has multiple organ dysfunction syndrome (MODS). Which of the following actions is the priority when planning care for this client?

Correct Answer is A

Explanation

Rationale:

A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

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