The emergency department team is performing cardiopulmonary resuscitation on a patient when the patient’s spouse arrives. What is the first action the nurse should take?
Ask the spouse if they wish to be present during the resuscitation.
Request that the patient’s spouse sit in the waiting room.
Refer the patient’s spouse to the hospital’s crisis team.
Suggest that the spouse begin to pray for the patient.
The Correct Answer is A
Choice A rationale:
It is crucial to prioritize the patient's spouse's emotional needs and preferences during this highly stressful and sensitive situation. Offering the choice to be present during resuscitation demonstrates respect for their autonomy, promotes family- centered care, and facilitates coping mechanisms.
Key considerations supporting this approach:
Respect for Autonomy:
Patients and their loved ones have the right to make informed decisions about their care, including being present during resuscitation efforts.
Respecting this right fosters trust, empowers the spouse, and aligns with ethical principles of patient autonomy. Family-Centered Care:
Family-centered care recognizes the importance of family members in the patient's care and decision-making.
Inviting the spouse to be present demonstrates a commitment to including them in the care process and supporting their emotional needs.
Facilitating Coping Mechanisms:
Witnessing resuscitation efforts can be distressing, but it can also provide closure, acceptance, and the opportunity to say goodbye.
Some individuals find comfort in being present and actively involved, even in difficult circumstances. The nurse can provide emotional support and guidance throughout the process.
Potential Benefits of Presence:
Studies have shown that family presence during resuscitation can have positive outcomes, such as decreased anxiety and post- traumatic stress disorder (PTSD) symptoms in family members.
It may also contribute to greater satisfaction with care and a sense of peace for those who choose to be present.
Rationales for other choices:
Choice B: Requesting that the spouse sit in the waiting room may isolate them and increase their anxiety. It deprives them of the opportunity to be involved in decision-making and potentially delays their grieving process.
Choice C: While the hospital's crisis team can provide valuable support, immediate referral may not align with the spouse's immediate needs or preferences. It's essential to first assess their emotional state and offer the choice of being present.
Choice D: Suggesting prayer may be appropriate for some individuals, but it should not be the first or only option presented. It's important to respect the spouse's spiritual beliefs and offer a range of support options.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While advancing age is a significant risk factor for cancer, it is not considered the single biggest risk factor. The risk of developing cancer does increase with age, primarily due to the accumulation of DNA damage over time. This damage can arise from various sources, including exposure to carcinogens, errors in DNA replication, and oxidative stress. With age, the body's ability to repair DNA damage also declines, making cells more susceptible to cancerous changes.
However, it's important to note that cancer can develop at any age, and even younger individuals can be affected if exposed to other significant risk factors.
Choice B rationale:
Exposure to tobacco is widely recognized as the single biggest risk factor for developing cancer. It is estimated to be responsible for about 25-30% of all cancer deaths worldwide.
Tobacco smoke contains over 70 known carcinogens, which are substances that can damage DNA and lead to cancer. These carcinogens can affect various organs in the body, including the lungs, mouth, throat, esophagus, stomach, pancreas, liver, bladder, kidney, cervix, and colon.
The risk of cancer increases with the amount and duration of tobacco use. Even exposure to secondhand smoke can increase the risk of cancer.
Quitting tobacco use is the most effective way to reduce the risk of cancer.
Choice C rationale:
Exposure to occupational chemicals is a known risk factor for certain types of cancer, such as lung cancer, bladder cancer, and leukemia. However, it is not considered the single biggest risk factor for developing cancer overall.
The risk of cancer from occupational chemicals depends on the specific chemical, the level of exposure, and the duration of exposure.
Workplace safety measures, such as using protective equipment and limiting exposure to hazardous chemicals, can help reduce the risk of cancer.
Choice D rationale:
Infection with certain viruses, known as oncoviruses, can increase the risk of developing certain types of cancer. For example, infection with human papillomavirus (HPV) can increase the risk of cervical cancer, and infection with hepatitis B virus (HBV) can increase the risk of liver cancer.
However, oncoviruses are not considered the single biggest risk factor for developing cancer overall. Vaccines are available to protect against some oncoviruses, such as HPV and HBV.
Correct Answer is D
Explanation
Choice A rationale:
While PICCs are typically intended for shorter-term use (up to 12 weeks), the fact that a PICC has been in place for 4 weeks is not, in itself, an immediate cause for concern. Regular assessment of the catheter and site is crucial, but the duration of placement alone does not warrant immediate attention.
Choice B rationale:
While it's generally recommended to change PICC dressings every 7 days, a dressing that is 3 days old is not an immediate emergency. The nurse should prioritize changing the dressing as soon as possible, but it does not require the same level of urgency as other potential complications.
Choice C rationale:
A missing securement device is a concern because it can increase the risk of catheter dislodgement or migration. However, it does not necessarily indicate an immediate threat to the patient's well-being. The nurse should promptly address the missing securement device, but it would not be the most pressing issue compared to swelling in the extremity.
Choice D rationale:
Swelling in the upper extremity where the PICC is located is a significant finding that demands immediate attention. It can be a sign of several serious complications, including:
Thrombosis: A blood clot within the vein, which can obstruct blood flow and lead to pain, swelling, and potentially more severe consequences like deep vein thrombosis (DVT) or pulmonary embolism (PE).
Infection: Inflammation and infection at the insertion site or within the bloodstream, which can cause swelling, redness, warmth, and pain. If left untreated, infection can progress to sepsis, a life-threatening condition.
Phlebitis: Inflammation of the vein, which can cause pain, redness, and swelling along the vein.
Infiltration: Leakage of fluids or medications into the surrounding tissue, leading to swelling and discomfort.
Prompt action is crucial in these cases to prevent further complications and ensure patient safety. The nurse should immediately notify the appropriate healthcare provider, initiate necessary interventions, and closely monitor the patient's condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.