Exhibits

Select from statement options to complete the sentence.

To assess outcomes, the nurse should consider information reported by the client and caregiver and focus on evaluating the client's

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and

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.

A. Assess the client's pain: The client has experienced significant trauma, undergone surgery, and may be in pain or discomfort as she regains consciousness. Pain assessment is crucial for adequate pain management and to prevent agitation or hemodynamic instability.
B. Increase the propofol infusion: Increasing sedation should not be the first response. Instead, assess the client’s pain and agitation, and if necessary, adjust sedation based on clinical need and provider recommendations.
C. Notify the social worker the client is awake: A social worker may be involved in care planning, but waking up does not require immediate notification.
D. Have the client sign consent forms for procedures already performed: If the client was incapacitated at the time of previous procedures, consent was likely obtained from a legal surrogate. Retroactive consent is not legally valid.
E. Consider extubating the client: The decision to extubate should be based on respiratory assessments, arterial blood gas (ABG) results, and overall stability, not just the client waking up.
F. Determine the client’s decision-making ability: As the client becomes more aware, it is important to assess cognitive function and orientation to determine if she can participate in decisions regarding her care. If the client is alert and coherent, she may be able to provide informed consent for further treatments.
G. Decrease the noise and light stimuli in the room as much as possible: Critically ill patients can become disoriented and agitated as they wake up. A calm environment helps reduce stress and delirium, improving recovery and promoting rest.
H. Explain all procedures: The client is waking up in an unfamiliar environment (intubated in the ICU), which can be frightening and disorienting. Explaining procedures provides reassurance and can help reduce anxiety and agitation.

Condition Most Likely Experiencing: Malignant Hyperthermia

• The client's tachycardia (HR 134/min), tachypnea (RR 28/min), hypotension (BP 92/52 mm Hg), and hypoxia (SpO₂ 89%) are key signs of malignant hyperthermia (MH), a life-threatening reaction to general anesthesia.
• While hyperthermia (elevated temperature) is a late sign, the presence of early indicators like tachycardia, tachypnea, and hypoxia strongly suggests MH.
• Incorrect choices:
  • Paralytic ileus (A): This is a possible secondary complication but not the primary issue.
  • Nausea and vomiting (B): Common post-op symptoms, but they don’t explain the severe vitals.
  • Hypercapnia (C): The client is hyperventilating, not hypoventilating.
  • Latex allergy (E): No signs of urticaria, anaphylaxis, or bronchospasm, which would indicate a latex allergy.

Correct Answer: Malignant hyperthermia

Two Actions to Take:

1. Administer dantrolene (C)
   • Dantrolene is the only effective antidote for MH. It directly relaxes skeletal muscles and stops the uncontrolled muscle metabolism that drives the crisis.
2. Monitor muscle rigidity (E)
   • Muscle rigidity is a hallmark sign of MH, especially in the jaw and upper body. The nurse must monitor for worsening rigidity as an indicator of disease progression.

• Incorrect choices:
  • Obtain the latex-free cart (A): There is no indication of a latex allergy.
  • Administer ondansetron (B): Useful for nausea and vomiting but does not address MH.
  • Insert an NG tube (D): Might be needed for paralytic ileus but is not a priority in treating MH.

Correct Answers: Administer dantrolene, Monitor muscle rigidity

Two Parameters to Monitor:

1. Bowel sounds (C)

   • Paralytic ileus can develop as a secondary complication of MH due to decreased blood flow to the intestines during the crisis. Monitoring bowel sounds helps detect this issue early.

2. Muscle rigidity (E)

   • Since sustained muscle contractions are a key feature of MH, tracking muscle rigidity helps assess whether the crisis is worsening or improving.

• Incorrect choices:
  • Blood pressure (A): While important, it is not a specific marker for MH progression.
  • Urine output (B): Useful for assessing kidney function but not directly related to MH management.
  • Skin integrity (D): Not a priority in this emergency.

Correct Answers: Bowel sounds, Muscle rigidity

Summary of Correct Answers:

• Condition Most Likely Experiencing: Malignant hyperthermia
• Two Actions to Take:Administer dantrolene, Monitor muscle rigidity
• Two Parameters to Monitor: Bowel sounds, Muscle rigidity