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 D

Explanation

A. "I stopped taking aspirin last week.": Stopping aspirin medication prior to surgery is often advised to reduce the risk of bleeding during and after the procedure. The nurse may confirm the timing of discontinuation with the client and verify if any other anticoagulant medications are being taken.

B. "I did not put my contact lenses in this morning.": Removing contact lenses before surgery is a routine precaution to prevent potential corneal abrasions or complications during the procedure. This statement indicates the client is following preoperative instructions.

C. "I took my blood pressure meds with a sip of water.": Taking blood pressure medications with a small amount of water is generally acceptable before surgery. However, the nurse may verify the specific medications the client is taking and their dosing schedule to ensure compliance.

D. "I had a cough and runny nose a couple days ago.": This statement requires further investigation as respiratory symptoms, such as cough and runny nose, may indicate an underlying respiratory infection. Infections can increase the risk of complications during surgery, such as anesthesia-related respiratory issues or postoperative infections. The nurse should assess the severity and duration of the symptoms, inquire about any fever or recent exposure to illnesses, and consider notifying the surgical team for further evaluation and decision-making regarding the client's surgical readiness.

A. Tachycardia B. Agonal breathing C. Chest pain D. Brainstem ischemia

Correct Answer is D

Explanation

Cushing's Triad is a set of three classic signs associated with increased intracranial pressure (ICP). These signs include hypertension, bradycardia, and irregular respirations. The presence of Cushing's Triad indicates severe brain injury or increased ICP, often leading to brainstem compression.

A. Tachycardia (Option A): Increased intracranial pressure can initially lead to tachycardia as the body attempts to compensate for the changes. However, as ICP continues to rise and brainstem compression occurs, the sympathetic response diminishes, resulting in bradycardia rather than tachycardia. Therefore, Cushing's Triad is not associated with preventing tachycardia.

B. Agonal breathing (Option B): Agonal breathing, characterized by gasping, labored breathing, or irregular breathing patterns, may occur as a result of brainstem dysfunction or damage. Cushing's Triad, indicative of increased ICP and impending brainstem herniation, does not prevent agonal breathing. In fact, irregular respirations are part of Cushing's Triad.

C. Chest pain (Option C): Chest pain may occur due to various cardiac or respiratory conditions and is not directly related to Cushing's Triad or increased intracranial pressure. Therefore, Cushing's Triad does not prevent chest pain.

D. Brainstem ischemia (Option D): Increased intracranial pressure can lead to brainstem compression, compromising blood flow to the brainstem and resulting in brainstem ischemia. Cushing's Triad, characterized by hypertension, bradycardia, and irregular respirations, is a nervous system response indicative of severe brain injury or increased ICP, which can lead to brainstem ischemia if left untreated. Therefore, Cushing's Triad is associated with brainstem ischemia rather than preventing it.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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