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Chapter 2 Care of the Critically Ill Patient
1)ʺResiliencyʺ in the American Association of Critical–Care Nurses synergy model refers to a personʹs:
1. Motivation to reduce anxiety through positive self–talk.
2. Ability to bounce back quickly after an insult.
3. Physical strength to endure extreme physical stressors.
4. Ability to return to a state of equilibrium.
Answer: 2
Explanation: 1. The correct definition of ʺresiliencyʺ is the ability to bounce back quickly after an insult. The
degree of resiliency is placed along a continuum between being unable to mount a response to
having strong reserves. Other characteristics of this model include: vulnerability, stability,
complexity, predictability, resource availability, participation in care, and participation in
decision making. #1 and #3 do not define resiliency and are not related to the synergy model
patient characteristics. #4, ʺstability,ʺ is defined as the ability to return to a state of equilibrium
and range between unresponsive to therapies and at high risk for death to stable and
responsive to therapy.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Safe, Effective Care Environment–Management of Care
2. The correct definition of ʺresiliencyʺ is the ability to bounce back quickly after an insult. The
degree of resiliency is placed along a continuum between being unable to mount a response to
having strong reserves. Other characteristics of this model include: vulnerability, stability,
complexity, predictability, resource availability, participation in care, and participation in
decision making. #1 and #3 do not define resiliency and are not related to the synergy model
patient characteristics. #4, ʺstability,ʺ is defined as the ability to return to a state of equilibrium
and range between unresponsive to therapies and at high risk for death to stable and
responsive to therapy.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Safe, Effective Care Environment–Management of Care
3. The correct definition of ʺresiliencyʺ is the ability to bounce back quickly after an insult. The
degree of resiliency is placed along a continuum between being unable to mount a response to
having strong reserves. Other characteristics of this model include: vulnerability, stability,
complexity, predictability, resource availability, participation in care, and participation in
decision making. #1 and #3 do not define resiliency and are not related to the synergy model
patient characteristics. #4, ʺstability,ʺ is defined as the ability to return to a state of equilibrium
and range between unresponsive to therapies and at high risk for death to stable and
responsive to therapy.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Safe, Effective Care Environment–Management of Care
4. The correct definition of ʺresiliencyʺ is the ability to bounce back quickly after an insult. The
degree of resiliency is placed along a continuum between being unable to mount a response to
having strong reserves. Other characteristics of this model include: vulnerability, stability,
complexity, predictability, resource availability, participation in care, and participation in
decision making. #1 and #3 do not define resiliency and are not related to the synergy model
patient characteristics. #4, ʺstability,ʺ is defined as the ability to return to a state of equilibrium
and range between unresponsive to therapies and at high risk for death to stable and
responsive to therapy.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 2–1: Explain the characteristics of the critically ill patient described in the AACN synergy model
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 222) Which of the following is the AACNʹs synergy model patient characteristic described as ʺthe intricate
entanglement of two or more systemsʺ?
1. Complexity
2. Predictability
3. Participation in care
4. Resource availability
Answer: 1
Explanation: 1. #2, #3, and #4 are other terms used in the synergy model.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Psychosocial Integrity
2. #2, #3, and #4 are other terms used in the synergy model.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Psychosocial Integrity
3. #2, #3, and #4 are other terms used in the synergy model.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Psychosocial Integrity
4. #2, #3, and #4 are other terms used in the synergy model.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Psychosocial Integrity
Learning Outcome: 2–1: Explain the characteristics of the critically ill patient described in the AACN synergy model
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 233) Which of the following stressors is one of the primary concerns of critically ill patients and should therefore be
included routinely in patient assessments?
1. Inability to control elimination
2. Lack of family support
3. Hunger
4. Altered ability to communicate
Answer: 4
Explanation: 1. Other items included in Cornockʹs categories are: being thirsty, having tubes in the mouth and
nose, being restricted by tubes/lines, being unable to sleep, and not being able to control
themselves. #1, #2, and #3 are incorrect. Although the inability to control elimination is similar
to not being able to control oneʹs self, the interpretation by Cornock does not include this
aspect as a stressor. Lack of family support and hunger were not identified as stressors by his
research.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Psychosocial Integrity
2. Other items included in Cornockʹs categories are: being thirsty, having tubes in the mouth and
nose, being restricted by tubes/lines, being unable to sleep, and not being able to control
themselves. #1, #2, and #3 are incorrect. Although the inability to control elimination is similar
to not being able to control oneʹs self, the interpretation by Cornock does not include this
aspect as a stressor. Lack of family support and hunger were not identified as stressors by his
research.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Psychosocial Integrity
3. Other items included in Cornockʹs categories are: being thirsty, having tubes in the mouth and
nose, being restricted by tubes/lines, being unable to sleep, and not being able to control
themselves. #1, #2, and #3 are incorrect. Although the inability to control elimination is similar
to not being able to control oneʹs self, the interpretation by Cornock does not include this
aspect as a stressor. Lack of family support and hunger were not identified as stressors by his
research.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Psychosocial Integrity
4. Other items included in Cornockʹs categories are: being thirsty, having tubes in the mouth and
nose, being restricted by tubes/lines, being unable to sleep, and not being able to control
themselves. #1, #2, and #3 are incorrect. Although the inability to control elimination is similar
to not being able to control oneʹs self, the interpretation by Cornock does not include this
aspect as a stressor. Lack of family support and hunger were not identified as stressors by his
research.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Learning Outcome: 2–2: Discuss the concerns expressed by critically ill patients
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 244) A patient has just completed a preoperative education session prior to undergoing coronary artery bypass
surgery. Which statement by the patient would indicate that he needs additional teaching by the nurse? (Select
all that apply.)
1.ʺI understand that I will have to blink my eyes to respond after the breathing tube is in my throat.ʺ
2.ʺI will be given frequent mouth care to help me when I am thirsty.ʺ
3.ʺI will be able to move about freely in bed and into the chair without help while connected to the
electronic equipment for monitoring.ʺ
4.ʺI may need something to help me rest due to the unfamiliar lights and sounds of the ICU unit.ʺ
Answer: 1, 2, 4
Explanation: 1. (Note: This requires multiple responses to be correct.)
The question is asking for the response that reflects inaccurate information. #3 reflects that the
patient did not understand the physical limitations and the need for assistance when moving
and getting in and out of bed. #1, #2, and #4 are correct understanding of the limitation
required by the patient in ICU. Alternate method of communication discussed in advance of
tube placement will assist in better communication after the tube is inserted to assist the
breathing process. While intubated, oral hygiene is needed to prevent mucosal drying due to
the inability of the patient to drink. Due to environmental lights, sounds, and difference in
sleeping environment, additional aids, such as drug management, may be needed to assist the
patient to rest at night.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
2. (Note: This requires multiple responses to be correct.)
The question is asking for the response that reflects inaccurate information. #3 reflects that the
patient did not understand the physical limitations and the need for assistance when moving
and getting in and out of bed. #1, #2, and #4 are correct understanding of the limitation
required by the patient in ICU. Alternate method of communication discussed in advance of
tube placement will assist in better communication after the tube is inserted to assist the
breathing process. While intubated, oral hygiene is needed to prevent mucosal drying due to
the inability of the patient to drink. Due to environmental lights, sounds, and difference in
sleeping environment, additional aids, such as drug management, may be needed to assist the
patient to rest at night.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
3. (Note: This requires multiple responses to be correct.)
The question is asking for the response that reflects inaccurate information. #3 reflects that the
patient did not understand the physical limitations and the need for assistance when moving
and getting in and out of bed. #1, #2, and #4 are correct understanding of the limitation
required by the patient in ICU. Alternate method of communication discussed in advance of
tube placement will assist in better communication after the tube is inserted to assist the
breathing process. While intubated, oral hygiene is needed to prevent mucosal drying due to
the inability of the patient to drink. Due to environmental lights, sounds, and difference in
sleeping environment, additional aids, such as drug management, may be needed to assist the
patient to rest at night.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 254. (Note: This requires multiple responses to be correct.)
The question is asking for the response that reflects inaccurate information. #3 reflects that the
patient did not understand the physical limitations and the need for assistance when moving
and getting in and out of bed. #1, #2, and #4 are correct understanding of the limitation
required by the patient in ICU. Alternate method of communication discussed in advance of
tube placement will assist in better communication after the tube is inserted to assist the
breathing process. While intubated, oral hygiene is needed to prevent mucosal drying due to
the inability of the patient to drink. Due to environmental lights, sounds, and difference in
sleeping environment, additional aids, such as drug management, may be needed to assist the
patient to rest at night.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 2–2: Discuss the concerns expressed by critically ill patients
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 265) When providing care to critically ill patients, whether they are responsive or unresponsive, the nurse should:
1. Clearly explain what care is to be done before starting the activity.
2. Perform the activity then let the patient rest without explaining the care.
3. Make sure the patient always responds and is cooperative before giving care.
4. Explain to the family that the patient will not understand or remember any of the discomfort associated
with care.
Answer: 1
Explanation: 1. By explaining to both the responsive and unresponsive patient, the nurse provides orientation,
reassurance, respect, and assessment of the patientʹs mental status. Seeking permission and
apologizing if discomfort is involved will also minimize the stress of the critically ill patient by
hearing what is about to occur. Even the unresponsive patient has been known to explain
procedures, conversations, and feelings once they have awakened. #2 is incorrect. If the patient
is not informed, autonomy and the right to choose have been violated; in addition the stress of
the unknown may be perceived incorrectly by the patient as an assault. #3 is incorrect. Some
unresponsive patients will never respond; therefore, the care would not be performed as
needed. Cooperation is also not possible in some cases whereby the patient has altered
thinking. Although the nurse desires these, the care should not be stopped just because they
cannot be obtained. Explaining should still be done and the care should proceed as needed. #4
is incorrect: The nurse cannot always reassure the family that the patient will not remember.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
2. By explaining to both the responsive and unresponsive patient, the nurse provides orientation,
reassurance, respect, and assessment of the patientʹs mental status. Seeking permission and
apologizing if discomfort is involved will also minimize the stress of the critically ill patient by
hearing what is about to occur. Even the unresponsive patient has been known to explain
procedures, conversations, and feelings once they have awakened. #2 is incorrect. If the patient
is not informed, autonomy and the right to choose have been violated; in addition the stress of
the unknown may be perceived incorrectly by the patient as an assault. #3 is incorrect. Some
unresponsive patients will never respond; therefore, the care would not be performed as
needed. Cooperation is also not possible in some cases whereby the patient has altered
thinking. Although the nurse desires these, the care should not be stopped just because they
cannot be obtained. Explaining should still be done and the care should proceed as needed. #4
is incorrect: The nurse cannot always reassure the family that the patient will not remember.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
3. By explaining to both the responsive and unresponsive patient, the nurse provides orientation,
reassurance, respect, and assessment of the patientʹs mental status. Seeking permission and
apologizing if discomfort is involved will also minimize the stress of the critically ill patient by
hearing what is about to occur. Even the unresponsive patient has been known to explain
procedures, conversations, and feelings once they have awakened. #2 is incorrect. If the patient
is not informed, autonomy and the right to choose have been violated; in addition the stress of
the unknown may be perceived incorrectly by the patient as an assault. #3 is incorrect. Some
unresponsive patients will never respond; therefore, the care would not be performed as
needed. Cooperation is also not possible in some cases whereby the patient has altered
thinking. Although the nurse desires these, the care should not be stopped just because they
cannot be obtained. Explaining should still be done and the care should proceed as needed. #4
is incorrect: The nurse cannot always reassure the family that the patient will not remember.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 274. By explaining to both the responsive and unresponsive patient, the nurse provides orientation,
reassurance, respect, and assessment of the patientʹs mental status. Seeking permission and
apologizing if discomfort is involved will also minimize the stress of the critically ill patient by
hearing what is about to occur. Even the unresponsive patient has been known to explain
procedures, conversations, and feelings once they have awakened. #2 is incorrect. If the patient
is not informed, autonomy and the right to choose have been violated; in addition the stress of
the unknown may be perceived incorrectly by the patient as an assault. #3 is incorrect. Some
unresponsive patients will never respond; therefore, the care would not be performed as
needed. Cooperation is also not possible in some cases whereby the patient has altered
thinking. Although the nurse desires these, the care should not be stopped just because they
cannot be obtained. Explaining should still be done and the care should proceed as needed. #4
is incorrect: The nurse cannot always reassure the family that the patient will not remember.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Learning Outcome: 2–3: Describe strategies a nurse might utilize to communicate with a ventilated patient
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 286) Which of the following communication strategies is most appropriate for a critical care nurse to use when
communicating with a ventilated patient? The nurse should:
1. Use professional terminology and provide the patient with detailed information.
2. Use simple language and explain in other terms if the patient does not seem to understand.
3. Provide minimal information so the patient is not overwhelmed.
4. Discuss issues primarily with the family because the patient is unlikely to understand the information.
Answer: 2
Explanation: 1. Simple laymanʹs language of information is better understood and by repeating or rephrasing
the patient gains a better understanding when in a stressful situation. #1 is incorrect.
Individuals who are not familiar with health care often do not understand professional
language. Confusion and a lack of understanding often result if the information is presented
only in professional terminology. #3 is incorrect. Minimal disclosure of information will
increase the stress of the patient by increasing confusion and concerns from the lack of
understanding about the illness or treatment process. Complete disclosure is the right of the
patient and the obligation of health care professionals. #4 is incorrect. Disclosing information or
communicating only with the patientʹs family denies the patient the right of choice and the
respect or dignity expected. Legally and ethically, except under very specific restrictions, the
patient has a right to know, and it is the health care professionalsʹ responsibility to explain
clearly for informed consent to occur.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
2. Simple laymanʹs language of information is better understood and by repeating or rephrasing
the patient gains a better understanding when in a stressful situation. #1 is incorrect.
Individuals who are not familiar with health care often do not understand professional
language. Confusion and a lack of understanding often result if the information is presented
only in professional terminology. #3 is incorrect. Minimal disclosure of information will
increase the stress of the patient by increasing confusion and concerns from the lack of
understanding about the illness or treatment process. Complete disclosure is the right of the
patient and the obligation of health care professionals. #4 is incorrect. Disclosing information or
communicating only with the patientʹs family denies the patient the right of choice and the
respect or dignity expected. Legally and ethically, except under very specific restrictions, the
patient has a right to know, and it is the health care professionalsʹ responsibility to explain
clearly for informed consent to occur.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
3. Simple laymanʹs language of information is better understood and by repeating or rephrasing
the patient gains a better understanding when in a stressful situation. #1 is incorrect.
Individuals who are not familiar with health care often do not understand professional
language. Confusion and a lack of understanding often result if the information is presented
only in professional terminology. #3 is incorrect. Minimal disclosure of information will
increase the stress of the patient by increasing confusion and concerns from the lack of
understanding about the illness or treatment process. Complete disclosure is the right of the
patient and the obligation of health care professionals. #4 is incorrect. Disclosing information or
communicating only with the patientʹs family denies the patient the right of choice and the
respect or dignity expected. Legally and ethically, except under very specific restrictions, the
patient has a right to know, and it is the health care professionalsʹ responsibility to explain
clearly for informed consent to occur.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 294. Simple laymanʹs language of information is better understood and by repeating or rephrasing
the patient gains a better understanding when in a stressful situation. #1 is incorrect.
Individuals who are not familiar with health care often do not understand professional
language. Confusion and a lack of understanding often result if the information is presented
only in professional terminology. #3 is incorrect. Minimal disclosure of information will
increase the stress of the patient by increasing confusion and concerns from the lack of
understanding about the illness or treatment process. Complete disclosure is the right of the
patient and the obligation of health care professionals. #4 is incorrect. Disclosing information or
communicating only with the patientʹs family denies the patient the right of choice and the
respect or dignity expected. Legally and ethically, except under very specific restrictions, the
patient has a right to know, and it is the health care professionalsʹ responsibility to explain
clearly for informed consent to occur.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Learning Outcome: 2–3: Describe strategies a nurse might utilize to communicate with a ventilated patient
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 307) During an assessment, a ventilated patient begins to frown and wiggle about in bed. Which assessment
strategy would be most helpful for the nurse to validate these observations?
1. Glasgow Scale
2. Maslowʹs hierarchy levels
3. Critical–Care Pain Observation Tool (CPOT)
4. Vital signs trends
Answer: 3
Explanation: 1. The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug
management in a patient who cannot speak due to intubation. Incorrect responses are #1, #2,
and #4. The Glasgow Coma Scale will identify the level of consciousness present to evaluate
the sedation level that is used with patients who are intubated. But this scale does not identify
the source of the problem that has increased the patientʹs facial changes or movement.
Maslowʹs hierarchy of needs prioritizes the needs based on essential to higher level functions
in the body, and it would not help identify the source of the changes noted in the patient. Vital
signs might tell the nurse that a change has occurred but it does not indicate the source of the
discomfort or problem.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Needs: Physiological Integrity–Reduction of Risk Potential
2. The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug
management in a patient who cannot speak due to intubation. Incorrect responses are #1, #2,
and #4. The Glasgow Coma Scale will identify the level of consciousness present to evaluate
the sedation level that is used with patients who are intubated. But this scale does not identify
the source of the problem that has increased the patientʹs facial changes or movement.
Maslowʹs hierarchy of needs prioritizes the needs based on essential to higher level functions
in the body, and it would not help identify the source of the changes noted in the patient. Vital
signs might tell the nurse that a change has occurred but it does not indicate the source of the
discomfort or problem.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Needs: Physiological Integrity–Reduction of Risk Potential
3. The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug
management in a patient who cannot speak due to intubation. Incorrect responses are #1, #2,
and #4. The Glasgow Coma Scale will identify the level of consciousness present to evaluate
the sedation level that is used with patients who are intubated. But this scale does not identify
the source of the problem that has increased the patientʹs facial changes or movement.
Maslowʹs hierarchy of needs prioritizes the needs based on essential to higher level functions
in the body, and it would not help identify the source of the changes noted in the patient. Vital
signs might tell the nurse that a change has occurred but it does not indicate the source of the
discomfort or problem.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Needs: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 314. The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug
management in a patient who cannot speak due to intubation. Incorrect responses are #1, #2,
and #4. The Glasgow Coma Scale will identify the level of consciousness present to evaluate
the sedation level that is used with patients who are intubated. But this scale does not identify
the source of the problem that has increased the patientʹs facial changes or movement.
Maslowʹs hierarchy of needs prioritizes the needs based on essential to higher level functions
in the body, and it would not help identify the source of the changes noted in the patient. Vital
signs might tell the nurse that a change has occurred but it does not indicate the source of the
discomfort or problem.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Needs: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 2–4: Explain the use of sedation, pain, and delirium scales with critically ill patients
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 328) Nurses in many ICUs are required to automatically attempt to wean sedation for their ventilated patients when
the patients meet certain parameters. Which of the following parameters would indicate that a patient in ICU is
ready for such an interruption in sedation, also sometimes known as a sedation vacation? The patient: (Select
all that apply.)
1. Activated the ventilator alarms but the alarms stopped spontaneously.
2. Frowned when turned but otherwise showed no muscular tension.
3. Had a MAP of 75 and heart rate of 76.
4. Was sleeping but awakened with verbal stimuli.
Answer: 1, 2, 3, 4
Explanation: 1. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are correct. Daily weaning of sedatives should automatically be attempted
when the patient meets the following criteria:
VAMASS is less than or equal to target VAMASS.
Sedation is not being used to treat delirium.
Patient is not receiving neuromuscular blocking agents.
Patient is hemodynamically stable.
Patient is stable on the ventilator.
Patientʹs pain is controlled.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are correct. Daily weaning of sedatives should automatically be attempted
when the patient meets the following criteria:
VAMASS is less than or equal to target VAMASS.
Sedation is not being used to treat delirium.
Patient is not receiving neuromuscular blocking agents.
Patient is hemodynamically stable.
Patient is stable on the ventilator.
Patientʹs pain is controlled.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are correct. Daily weaning of sedatives should automatically be attempted
when the patient meets the following criteria:
VAMASS is less than or equal to target VAMASS.
Sedation is not being used to treat delirium.
Patient is not receiving neuromuscular blocking agents.
Patient is hemodynamically stable.
Patient is stable on the ventilator.
Patientʹs pain is controlled.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 334. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are correct. Daily weaning of sedatives should automatically be attempted
when the patient meets the following criteria:
VAMASS is less than or equal to target VAMASS.
Sedation is not being used to treat delirium.
Patient is not receiving neuromuscular blocking agents.
Patient is hemodynamically stable.
Patient is stable on the ventilator.
Patientʹs pain is controlled.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 2–4: Explain the use of sedation, pain, and delirium scales with critically ill patients
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 349) A patient scores positive on the Confusion Assessment Method of the Intensive Care Unit (CAM–ICU). Which
of the following nursing diagnoses would have the highest priority based on this positive score?
1. Injury, Risk for
2. Family Processes, Altered
3. Social Interaction, Impaired
4. Memory Impaired
Answer: 1
Explanation: 1. Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect.
Social interactions fall in the Love/Belonging category, which is in the next highest level. #4 is
incorrect. Mental impairment falls in the Self–esteem level, which is the next highest level.
(Note: No example of the Self–actualization level was given and is the highest level of need
according to Maslowʹs theory)
Nursing Process: Implementation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
2. Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect.
Social interactions fall in the Love/Belonging category, which is in the next highest level. #4 is
incorrect. Mental impairment falls in the Self–esteem level, which is the next highest level.
(Note: No example of the Self–actualization level was given and is the highest level of need
according to Maslowʹs theory)
Nursing Process: Implementation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
3. Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect.
Social interactions fall in the Love/Belonging category, which is in the next highest level. #4 is
incorrect. Mental impairment falls in the Self–esteem level, which is the next highest level.
(Note: No example of the Self–actualization level was given and is the highest level of need
according to Maslowʹs theory)
Nursing Process: Implementation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
4. Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect.
Social interactions fall in the Love/Belonging category, which is in the next highest level. #4 is
incorrect. Mental impairment falls in the Self–esteem level, which is the next highest level.
(Note: No example of the Self–actualization level was given and is the highest level of need
according to Maslowʹs theory)
Nursing Process: Implementation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 2–4: Explain the use of sedation, pain, and delirium scales with critically ill patients
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 3510) A nurse is beginning an intravenous infusion of morphine sulfate on her post–op ventilated patient. When
initiating the infusion and for the first few hours, the nurse should do which of the following?
1. Anticipate that the patient will begin to experience the effect of the morphine 5 minutes after the start of
the infusion.
2. Begin the infusion at the lowest ordered dose and increase the rate every 5 minutes if the patient
continues to have pain.
3. Complete the Critical–Care Pain Observation Tool scale 5 minutes after increasing the infusion rate each
time.
4. Provide additional intermittent boluses of morphine sulfate if the patient experiences breakthrough pain.
Answer: 4
Explanation: 1. Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine
sulfate, start to act immediately; however, they will not provide significant analgesia until the
infusion reaches ʺsteady state.ʺ At the initiation of an infusion and when the infusion rate is
increased, loading doses must be administered in order to provide immediate analgesia and
maintain the desired analgesia until the infusion reaches steady state. Thus, a critically ill
patient often will receive an IV bolus of an analgesic followed by an ongoing infusion of the
pain medication with intermittent boluses and increases in infusion until the drug attains
steady state and the patient experiences pain relief. In response to anticipated painful
procedures (e.g., turning) the patient might receive an additional bolus. When IV infusion rates
are repeatedly increased versus the administration of intermittent boluses as a means of
responding to acute pain, the risk for excessive analgesia dosing exists.
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine
sulfate, start to act immediately; however, they will not provide significant analgesia until the
infusion reaches ʺsteady state.ʺ At the initiation of an infusion and when the infusion rate is
increased, loading doses must be administered in order to provide immediate analgesia and
maintain the desired analgesia until the infusion reaches steady state. Thus, a critically ill
patient often will receive an IV bolus of an analgesic followed by an ongoing infusion of the
pain medication with intermittent boluses and increases in infusion until the drug attains
steady state and the patient experiences pain relief. In response to anticipated painful
procedures (e.g., turning) the patient might receive an additional bolus. When IV infusion rates
are repeatedly increased versus the administration of intermittent boluses as a means of
responding to acute pain, the risk for excessive analgesia dosing exists.
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine
sulfate, start to act immediately; however, they will not provide significant analgesia until the
infusion reaches ʺsteady state.ʺ At the initiation of an infusion and when the infusion rate is
increased, loading doses must be administered in order to provide immediate analgesia and
maintain the desired analgesia until the infusion reaches steady state. Thus, a critically ill
patient often will receive an IV bolus of an analgesic followed by an ongoing infusion of the
pain medication with intermittent boluses and increases in infusion until the drug attains
steady state and the patient experiences pain relief. In response to anticipated painful
procedures (e.g., turning) the patient might receive an additional bolus. When IV infusion rates
are repeatedly increased versus the administration of intermittent boluses as a means of
responding to acute pain, the risk for excessive analgesia dosing exists.
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 364. Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine
sulfate, start to act immediately; however, they will not provide significant analgesia until the
infusion reaches ʺsteady state.ʺ At the initiation of an infusion and when the infusion rate is
increased, loading doses must be administered in order to provide immediate analgesia and
maintain the desired analgesia until the infusion reaches steady state. Thus, a critically ill
patient often will receive an IV bolus of an analgesic followed by an ongoing infusion of the
pain medication with intermittent boluses and increases in infusion until the drug attains
steady state and the patient experiences pain relief. In response to anticipated painful
procedures (e.g., turning) the patient might receive an additional bolus. When IV infusion rates
are repeatedly increased versus the administration of intermittent boluses as a means of
responding to acute pain, the risk for excessive analgesia dosing exists.
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 2–5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation,
pain and delirium in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 3711) Which of the following strategies should the nurse include in the plan of care when trying to minimize sleep
disruptions for a patient in an ICU? (Select all that apply.)
1. Instituting a short course of therapy for sleeping agents
2. Accurate scoring and vigilance in sedation and sedation scoring
3. Managing the environment to reduce lighting, sounds, and so on
4. Minimizing staff interruptions during sleep periods
5. Scheduling treatments only during the day or at least 4 hours apart at night
Answer: 1, 2, 3, 4
Explanation: 1. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize
the rest benefits that will shorten the duration of care based on research findings. #5 is
incorrect. Planning the care for only the day hours or at least 4 hours is not practical to
improve the outcomes of the client, because some medications, therapies, and assessments
need to be made around the clock for the greatest benefits to patients. The minimum time for
resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep
fragmentation and improve restful sleep.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
2. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize
the rest benefits that will shorten the duration of care based on research findings. #5 is
incorrect. Planning the care for only the day hours or at least 4 hours is not practical to
improve the outcomes of the client, because some medications, therapies, and assessments
need to be made around the clock for the greatest benefits to patients. The minimum time for
resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep
fragmentation and improve restful sleep.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
3. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize
the rest benefits that will shorten the duration of care based on research findings. #5 is
incorrect. Planning the care for only the day hours or at least 4 hours is not practical to
improve the outcomes of the client, because some medications, therapies, and assessments
need to be made around the clock for the greatest benefits to patients. The minimum time for
resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep
fragmentation and improve restful sleep.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
4. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize
the rest benefits that will shorten the duration of care based on research findings. #5 is
incorrect. Planning the care for only the day hours or at least 4 hours is not practical to
improve the outcomes of the client, because some medications, therapies, and assessments
need to be made around the clock for the greatest benefits to patients. The minimum time for
resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep
fragmentation and improve restful sleep.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 385. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize
the rest benefits that will shorten the duration of care based on research findings. #5 is
incorrect. Planning the care for only the day hours or at least 4 hours is not practical to
improve the outcomes of the client, because some medications, therapies, and assessments
need to be made around the clock for the greatest benefits to patients. The minimum time for
resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep
fragmentation and improve restful sleep.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
Learning Outcome: 2–5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation,
pain and delirium in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 3912) A nurse is confirming the medication orders and schedule for sedative administration to a patient with
delirium. Which of the following schedules would maximize the effectiveness of the drugs? Administration of
medication:
1. Only in the early morning.
2. Only at bedtime (HS).
3. Around the clock with higher dosages in the evening.
4. Only on an as–needed (PRN) basis.
Answer: 3
Explanation: 1. Timing given around the clock with a greater dosage in the evening will match the symptom of
undowning when the symptoms appear the greatest later in the day. #1, #2, and #4 are
incorrect. Timing would not reflect the symptoms nor control the condition equally throughout
the 24–hour period. Additional dosages besides the dosage around the clock can be given on a
PRN basis when acute exacerbations occur.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. Timing given around the clock with a greater dosage in the evening will match the symptom of
undowning when the symptoms appear the greatest later in the day. #1, #2, and #4 are
incorrect. Timing would not reflect the symptoms nor control the condition equally throughout
the 24–hour period. Additional dosages besides the dosage around the clock can be given on a
PRN basis when acute exacerbations occur.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. Timing given around the clock with a greater dosage in the evening will match the symptom of
undowning when the symptoms appear the greatest later in the day. #1, #2, and #4 are
incorrect. Timing would not reflect the symptoms nor control the condition equally throughout
the 24–hour period. Additional dosages besides the dosage around the clock can be given on a
PRN basis when acute exacerbations occur.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. Timing given around the clock with a greater dosage in the evening will match the symptom of
undowning when the symptoms appear the greatest later in the day. #1, #2, and #4 are
incorrect. Timing would not reflect the symptoms nor control the condition equally throughout
the 24–hour period. Additional dosages besides the dosage around the clock can be given on a
PRN basis when acute exacerbations occur.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 2–5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation,
pain and delirium in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 4013) Which of the following patients would be considered at risk for nutritional imbalances? A patient: (Select all
that apply.)
1. Who is a stable post–MI.
2. With renal dysfunctions/failure.
3. With slightly elevated liver enzymes.
4. With burns or excessive trauma.
5. Who is intubated and sedated.
Answer: 1, 2, 4, 5
Explanation: 1. (Note: This requires multiple responses to be correct.)
All of these patients need additional calories, alterations in types of nutrition given, or an
alternate form of nutritional delivery to maintain or achieve nutritional balance based on
physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and
alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver
enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods,
and an increase protein may be needed.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. (Note: This requires multiple responses to be correct.)
All of these patients need additional calories, alterations in types of nutrition given, or an
alternate form of nutritional delivery to maintain or achieve nutritional balance based on
physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and
alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver
enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods,
and an increase protein may be needed.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. (Note: This requires multiple responses to be correct.)
All of these patients need additional calories, alterations in types of nutrition given, or an
alternate form of nutritional delivery to maintain or achieve nutritional balance based on
physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and
alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver
enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods,
and an increase protein may be needed.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. (Note: This requires multiple responses to be correct.)
All of these patients need additional calories, alterations in types of nutrition given, or an
alternate form of nutritional delivery to maintain or achieve nutritional balance based on
physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and
alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver
enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods,
and an increase protein may be needed.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 415. (Note: This requires multiple responses to be correct.)
All of these patients need additional calories, alterations in types of nutrition given, or an
alternate form of nutritional delivery to maintain or achieve nutritional balance based on
physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and
alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver
enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods,
and an increase protein may be needed.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 2–6: Compare and contrast the use of enteral and parenteral nutrition in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 4214) While members of the multidisciplinary team are reviewing a patientʹs nutritional status, they note the
following values. Which of the values would need additional investigation?
1. A serum albumin of more than 3.5 g/dL or 35 g/L
2. A weight increase of 1.5 kg in a day
3. A serum hemoglobin of 11.7 g/dL or 117 mmol/L
4. A serum magnesium of 1.6 mg/dL or 132 mEq/L
Answer: 2
Explanation: 1. A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid.
Additional assessment needs to be done to evaluate the cause and risks. #1, #3, and #4 are
incorrect. These lab values are at the lower end of the normal levels for adults and do not
require additional assessment or interventions. However, if the albumin drops below 3.5 g/dL,
then the declining lab may reflect changes in the protein status of the body that should be
further assessed.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid.
Additional assessment needs to be done to evaluate the cause and risks. #1, #3, and #4 are
incorrect. These lab values are at the lower end of the normal levels for adults and do not
require additional assessment or interventions. However, if the albumin drops below 3.5 g/dL,
then the declining lab may reflect changes in the protein status of the body that should be
further assessed.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid.
Additional assessment needs to be done to evaluate the cause and risks. #1, #3, and #4 are
incorrect. These lab values are at the lower end of the normal levels for adults and do not
require additional assessment or interventions. However, if the albumin drops below 3.5 g/dL,
then the declining lab may reflect changes in the protein status of the body that should be
further assessed.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid.
Additional assessment needs to be done to evaluate the cause and risks. #1, #3, and #4 are
incorrect. These lab values are at the lower end of the normal levels for adults and do not
require additional assessment or interventions. However, if the albumin drops below 3.5 g/dL,
then the declining lab may reflect changes in the protein status of the body that should be
further assessed.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 2–6: Compare and contrast the use of enteral and parenteral nutrition in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 4315) A nurse has inserted a nasogastric tube and is planning to confirm placement of the tube prior to starting
enteral feedings. Which of the following is the most accurate method for confirming placement? By:
1. Obtaining a radiological x–ray of the abdomen.
2. Checking gastric aspirate for a pH of less than 7.
3. Instilling 30 mL of air while listening with a stethoscope when placed over the fundus of the stomach.
4. Determining the presence of carbon dioxide.
Answer: 1
Explanation: 1. It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to
validate placement. #2 and #3 might be procedures used to validate placement; however, the
pH in #2 is too high and air auscultation has been shown to be inaccurate.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to
validate placement. #2 and #3 might be procedures used to validate placement; however, the
pH in #2 is too high and air auscultation has been shown to be inaccurate.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to
validate placement. #2 and #3 might be procedures used to validate placement; however, the
pH in #2 is too high and air auscultation has been shown to be inaccurate.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to
validate placement. #2 and #3 might be procedures used to validate placement; however, the
pH in #2 is too high and air auscultation has been shown to be inaccurate.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 2–6: Compare and contrast the use of enteral and parenteral nutrition in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 4416) Which of the following nursing diagnoses should receive the highest priority when caring for a patient who is
receiving total parenteral nutrition?
1. Infection, Risk for
2. Trauma, Risk for
3. Skin Integrity, Impaired
4. Fluid Volume, Risk for Imbalance
Answer: 1
Explanation: 1. #1 is the greatest risk for the parenteral nutrition patient due to the high glucose present, the
central vein access route, and the declining nutritional status that the patient is in when this
therapy is started. Absolute sterility, close assessment of glucose balances that are maintained
by additional insulin treatment, and the need to maximize nutritional intake for healing to
occur will minimize the risk of infection. #2, #3, and #4 are still important in the planning
process for the care to this patient, but the infection risk can be deadly to this patient. Avoiding
trauma at the site or other parts of the body should be routinely done to ʺdo no harmʺ and
avoid injury where possible. Skin integrity will be impaired due to poor nutritional intake, but
preventive measures can be done to decrease the risk. Fluid volume imbalances are minimized
by accurate regulators to limit fluid overload or to run at the appropriate rate to provide the
essential nutrition needed. Standards of care for pump regulation minimize both the fluid
overload and fluid deficits that might occur if solutions were freely hung to be regulated by
drop methods.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
2. #1 is the greatest risk for the parenteral nutrition patient due to the high glucose present, the
central vein access route, and the declining nutritional status that the patient is in when this
therapy is started. Absolute sterility, close assessment of glucose balances that are maintained
by additional insulin treatment, and the need to maximize nutritional intake for healing to
occur will minimize the risk of infection. #2, #3, and #4 are still important in the planning
process for the care to this patient, but the infection risk can be deadly to this patient. Avoiding
trauma at the site or other parts of the body should be routinely done to ʺdo no harmʺ and
avoid injury where possible. Skin integrity will be impaired due to poor nutritional intake, but
preventive measures can be done to decrease the risk. Fluid volume imbalances are minimized
by accurate regulators to limit fluid overload or to run at the appropriate rate to provide the
essential nutrition needed. Standards of care for pump regulation minimize both the fluid
overload and fluid deficits that might occur if solutions were freely hung to be regulated by
drop methods.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 453. #1 is the greatest risk for the parenteral nutrition patient due to the high glucose present, the
central vein access route, and the declining nutritional status that the patient is in when this
therapy is started. Absolute sterility, close assessment of glucose balances that are maintained
by additional insulin treatment, and the need to maximize nutritional intake for healing to
occur will minimize the risk of infection. #2, #3, and #4 are still important in the planning
process for the care to this patient, but the infection risk can be deadly to this patient. Avoiding
trauma at the site or other parts of the body should be routinely done to ʺdo no harmʺ and
avoid injury where possible. Skin integrity will be impaired due to poor nutritional intake, but
preventive measures can be done to decrease the risk. Fluid volume imbalances are minimized
by accurate regulators to limit fluid overload or to run at the appropriate rate to provide the
essential nutrition needed. Standards of care for pump regulation minimize both the fluid
overload and fluid deficits that might occur if solutions were freely hung to be regulated by
drop methods.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
4. #1 is the greatest risk for the parenteral nutrition patient due to the high glucose present, the
central vein access route, and the declining nutritional status that the patient is in when this
therapy is started. Absolute sterility, close assessment of glucose balances that are maintained
by additional insulin treatment, and the need to maximize nutritional intake for healing to
occur will minimize the risk of infection. #2, #3, and #4 are still important in the planning
process for the care to this patient, but the infection risk can be deadly to this patient. Avoiding
trauma at the site or other parts of the body should be routinely done to ʺdo no harmʺ and
avoid injury where possible. Skin integrity will be impaired due to poor nutritional intake, but
preventive measures can be done to decrease the risk. Fluid volume imbalances are minimized
by accurate regulators to limit fluid overload or to run at the appropriate rate to provide the
essential nutrition needed. Standards of care for pump regulation minimize both the fluid
overload and fluid deficits that might occur if solutions were freely hung to be regulated by
drop methods.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 2–6: Compare and contrast the use of enteral and parenteral nutrition in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 4617) When planning care to meet the needs of family members of a critically ill patient, the nurse should include:
(Select all that apply.)
1. Expressing an attitude of hope, honesty, open communication, and caring.
2. Stating specific facts about the patientʹs condition in timely manner.
3. Planning regular times for family visits throughout the day.
4. Limiting the number of visitors to significant others.
5. Communicating to a single family member to cut down time wasted repeating information to all visitors.
Answer: 1, 2, 3
Explanation: 1. (Note: This requires multiple responses to be correct.)
#1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient.
An open access by the significant others of the patient has been validated by research to
improve medical outcomes. A sense of concern for the patient will reduce stress within the
family, and clear simple explanations will maximize the communication process to a stressed
family member. #4: Although some number limitations are needed, the persons are not to be
screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic
for the patient. If the visitor (family or friend) increases problems with the patient, then the
visitor should be restricted access until the condition improves. #5: Although communicating
with a single person will minimize the repeating of information, a core group of individuals
can be used to distribute information to other family members, particularly if a large
population is present. Therefore, restricting to one person is too limiting but a minimal core
group can be helpful in other situations, especially if the nurse is needed at the bedside. A case
manager, clergy, or staff support person could also be used to pass on information when the
nursing staff is too busy caring for the patient.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
2. (Note: This requires multiple responses to be correct.)
#1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient.
An open access by the significant others of the patient has been validated by research to
improve medical outcomes. A sense of concern for the patient will reduce stress within the
family, and clear simple explanations will maximize the communication process to a stressed
family member. #4: Although some number limitations are needed, the persons are not to be
screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic
for the patient. If the visitor (family or friend) increases problems with the patient, then the
visitor should be restricted access until the condition improves. #5: Although communicating
with a single person will minimize the repeating of information, a core group of individuals
can be used to distribute information to other family members, particularly if a large
population is present. Therefore, restricting to one person is too limiting but a minimal core
group can be helpful in other situations, especially if the nurse is needed at the bedside. A case
manager, clergy, or staff support person could also be used to pass on information when the
nursing staff is too busy caring for the patient.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 473. (Note: This requires multiple responses to be correct.)
#1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient.
An open access by the significant others of the patient has been validated by research to
improve medical outcomes. A sense of concern for the patient will reduce stress within the
family, and clear simple explanations will maximize the communication process to a stressed
family member. #4: Although some number limitations are needed, the persons are not to be
screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic
for the patient. If the visitor (family or friend) increases problems with the patient, then the
visitor should be restricted access until the condition improves. #5: Although communicating
with a single person will minimize the repeating of information, a core group of individuals
can be used to distribute information to other family members, particularly if a large
population is present. Therefore, restricting to one person is too limiting but a minimal core
group can be helpful in other situations, especially if the nurse is needed at the bedside. A case
manager, clergy, or staff support person could also be used to pass on information when the
nursing staff is too busy caring for the patient.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
4. (Note: This requires multiple responses to be correct.)
#1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient.
An open access by the significant others of the patient has been validated by research to
improve medical outcomes. A sense of concern for the patient will reduce stress within the
family, and clear simple explanations will maximize the communication process to a stressed
family member. #4: Although some number limitations are needed, the persons are not to be
screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic
for the patient. If the visitor (family or friend) increases problems with the patient, then the
visitor should be restricted access until the condition improves. #5: Although communicating
with a single person will minimize the repeating of information, a core group of individuals
can be used to distribute information to other family members, particularly if a large
population is present. Therefore, restricting to one person is too limiting but a minimal core
group can be helpful in other situations, especially if the nurse is needed at the bedside. A case
manager, clergy, or staff support person could also be used to pass on information when the
nursing staff is too busy caring for the patient.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
5. (Note: This requires multiple responses to be correct.)
#1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient.
An open access by the significant others of the patient has been validated by research to
improve medical outcomes. A sense of concern for the patient will reduce stress within the
family, and clear simple explanations will maximize the communication process to a stressed
family member. #4: Although some number limitations are needed, the persons are not to be
screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic
for the patient. If the visitor (family or friend) increases problems with the patient, then the
visitor should be restricted access until the condition improves. #5: Although communicating
with a single person will minimize the repeating of information, a core group of individuals
can be used to distribute information to other family members, particularly if a large
population is present. Therefore, restricting to one person is too limiting but a minimal core
group can be helpful in other situations, especially if the nurse is needed at the bedside. A case
manager, clergy, or staff support person could also be used to pass on information when the
nursing staff is too busy caring for the patient.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 48Learning Outcome: 2–7: Discuss ways to identify and meet the needs of families of critically ill patients
18) Which of the following statements describing the needs of family members of critically ill patients has not been
validated by research?
1. ʺ ʹNot knowing is the worst partʹ of waiting.ʺ
2. Families in the waiting room have no effect on patient outcomes.
3.ʺHoveringʺ in the proximity phase is characterized by confusion and tension.
4. A unified message from staff minimizes family stressors.
Answer: 2
Explanation: 1. #2 is an incorrect statement that is not supported by research. In fact the family support has
been proven to clinical outcomes. #1, #3, and #4 are supported by research and are accurate to
the findings about the family needs of the critically ill patient. Therefore, communication
should remain open and freely given with a single message to minimize confusion and stress.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
2. #2 is an incorrect statement that is not supported by research. In fact the family support has
been proven to clinical outcomes. #1, #3, and #4 are supported by research and are accurate to
the findings about the family needs of the critically ill patient. Therefore, communication
should remain open and freely given with a single message to minimize confusion and stress.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
3. #2 is an incorrect statement that is not supported by research. In fact the family support has
been proven to clinical outcomes. #1, #3, and #4 are supported by research and are accurate to
the findings about the family needs of the critically ill patient. Therefore, communication
should remain open and freely given with a single message to minimize confusion and stress.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
4. #2 is an incorrect statement that is not supported by research. In fact the family support has
been proven to clinical outcomes. #1, #3, and #4 are supported by research and are accurate to
the findings about the family needs of the critically ill patient. Therefore, communication
should remain open and freely given with a single message to minimize confusion and stress.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
Learning Outcome: 2–7: Discuss ways to identify and meet the needs of families of critically ill patients
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 4919) Which of the following is not one of the family needs identified in Leskeʹs 1991 research?
1. Proximity
2. Information
3. Assurance
4. Timeliness
Answer: 4
Explanation: 1. Timeliness is not a term/concept that is presented in Leskeʹs research findings. Other concepts
that are presented include: Support and Comfort. (This question is asking which concept is
NOT included.) #1, #2, #3 are concepts that are presented by Leskeʹs research findings.
Nursing Process: Planning
Cognitive Level: Knowledge
Category of Need: Psychosocial Integrity
2. Timeliness is not a term/concept that is presented in Leskeʹs research findings. Other concepts
that are presented include: Support and Comfort. (This question is asking which concept is
NOT included.) #1, #2, #3 are concepts that are presented by Leskeʹs research findings.
Nursing Process: Planning
Cognitive Level: Knowledge
Category of Need: Psychosocial Integrity
3. Timeliness is not a term/concept that is presented in Leskeʹs research findings. Other concepts
that are presented include: Support and Comfort. (This question is asking which concept is
NOT included.) #1, #2, #3 are concepts that are presented by Leskeʹs research findings.
Nursing Process: Planning
Cognitive Level: Knowledge
Category of Need: Psychosocial Integrity
4. Timeliness is not a term/concept that is presented in Leskeʹs research findings. Other concepts
that are presented include: Support and Comfort. (This question is asking which concept is
NOT included.) #1, #2, #3 are concepts that are presented by Leskeʹs research findings.
Nursing Process: Planning
Cognitive Level: Knowledge
Category of Need: Psychosocial Integrity
Learning Outcome: 2–7: Discuss ways to identify and meet the needs of families of critically ill patients
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 5020) When planning care for the families of critically ill patients, the nurse would include which of the strategies by
Miracle (2006) to meet family needs? (Select all that apply.)
1. Regular family conferences to meet patient goals/progress
2. Frequent verbal communication to clarify the purpose of unit, equipment, procedures, waiting areas,
phones, and so on
3. A way to contact family through a specific family member by phone if needed
4. Information about how to contact the primary doctor if needed
5. A consistent nurse and unified staff responses if that nurse is not available
Answer: 1, 2, 4, 5
Explanation: 1. (Note: This requires multiple responses to be correct.)
Each of these strategies is suggested to minimize stress and maximize communication to meet
the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets,
rules, and regulations are better received and retained more than verbal instructions. Written
communications can be reread and clearly understood as a cross–reference by the family
during the stressful period of waiting for their patientʹs recovery. Frequently repeating
information is better for retention but often is a waste of the nurseʹs time for basic information
that remains the same for all patients. By printing information, this allows the nurse to give
more information about the patientʹs condition rather than focusing on basic rules and
regulations.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Psychosocial Integrity
2. (Note: This requires multiple responses to be correct.)
Each of these strategies is suggested to minimize stress and maximize communication to meet
the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets,
rules, and regulations are better received and retained more than verbal instructions. Written
communications can be reread and clearly understood as a cross–reference by the family
during the stressful period of waiting for their patientʹs recovery. Frequently repeating
information is better for retention but often is a waste of the nurseʹs time for basic information
that remains the same for all patients. By printing information, this allows the nurse to give
more information about the patientʹs condition rather than focusing on basic rules and
regulations.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Psychosocial Integrity
3. (Note: This requires multiple responses to be correct.)
Each of these strategies is suggested to minimize stress and maximize communication to meet
the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets,
rules, and regulations are better received and retained more than verbal instructions. Written
communications can be reread and clearly understood as a cross–reference by the family
during the stressful period of waiting for their patientʹs recovery. Frequently repeating
information is better for retention but often is a waste of the nurseʹs time for basic information
that remains the same for all patients. By printing information, this allows the nurse to give
more information about the patientʹs condition rather than focusing on basic rules and
regulations.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 514. (Note: This requires multiple responses to be correct.)
Each of these strategies is suggested to minimize stress and maximize communication to meet
the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets,
rules, and regulations are better received and retained more than verbal instructions. Written
communications can be reread and clearly understood as a cross–reference by the family
during the stressful period of waiting for their patientʹs recovery. Frequently repeating
information is better for retention but often is a waste of the nurseʹs time for basic information
that remains the same for all patients. By printing information, this allows the nurse to give
more information about the patientʹs condition rather than focusing on basic rules and
regulations.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Psychosocial Integrity
5. (Note: This requires multiple responses to be correct.)
Each of these strategies is suggested to minimize stress and maximize communication to meet
the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets,
rules, and regulations are better received and retained more than verbal instructions. Written
communications can be reread and clearly understood as a cross–reference by the family
during the stressful period of waiting for their patientʹs recovery. Frequently repeating
information is better for retention but often is a waste of the nurseʹs time for basic information
that remains the same for all patients. By printing information, this allows the nurse to give
more information about the patientʹs condition rather than focusing on basic rules and
regulations.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Learning Outcome: 2–7: Discuss ways to identify and meet the needs of families of critically ill patients
21) A physician suggests that a ventilated patient needing immediate transport to CT scan and having severe pain
be given IV fentanyl rather than morphine sulfate for pain management. One reason the physician might
recommend the use of fentanyl is:
1. It has a more rapid onset and a shorter duration of action.
2. It is not likely to cause respiratory depression.
3. Rapid administration does not have any hemodynamic consequences.
4. Weaning of a continuous infusion is never needed due to its short half–life.
Answer: 1
Explanation: 1. Fentanyl is a commonly used medication.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. Fentanyl is a commonly used medication.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. Fentanyl is a commonly used medication.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. Fentanyl is a commonly used medication.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 2–5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation,
pain, and delirium in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 5222) A ventilated patient is receiving midazolam (Versed) for sedation. The nurse would recognize that the patient
is receiving an appropriate dose of midazolam when the patient is:
1. Awake with a heart rate of 124 and attempting to pull out the IV.
2. Awake with a respiratory rate of 38 and a heart rate of 132.
3. Asleep but withdrawing to noxious stimuli with a heart rate of 80.
4. Asleep but awakening to light touch with a heart rate of 72.
Answer: 4
Explanation: 1. Commonly used medication: Midazolam and AACN Sedation Assessment Scale
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
2. Commonly used medication: Midazolam and AACN Sedation Assessment Scale
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
3. Commonly used medication: Midazolam and AACN Sedation Assessment Scale
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
4. Commonly used medication: Midazolam and AACN Sedation Assessment Scale
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 2–5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation,
pain, and delirium in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 5323) A nurse is caring for a ventilated post–op patient who she suspects is experiencing pain. Which method of
assessing if the patient is actually in pain should the nurse try first?
1. Attempting an analgesic trial
2. Asking a family member if she thinks the patient is in pain
3. Observing the patientʹs face for grimacing
4. Asking the patient if he is in pain
Answer: 4
Explanation: 1. McCaffery described a hierarchy of pain assessment techniques, including:
Patient self–report.
Search for a potential cause of a change in patient behavior.
Observation of patient behaviors when patient self–report is not possible.
Surrogate report of a patientʹs pain or patientʹs behavior change.
Nursing Process: Assessment
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Physiological Adaptations
2. McCaffery described a hierarchy of pain assessment techniques, including:
Patient self–report.
Search for a potential cause of a change in patient behavior.
Observation of patient behaviors when patient self–report is not possible.
Surrogate report of a patientʹs pain or patientʹs behavior change.
Nursing Process: Assessment
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Physiological Adaptations
3. McCaffery described a hierarchy of pain assessment techniques, including:
Patient self–report.
Search for a potential cause of a change in patient behavior.
Observation of patient behaviors when patient self–report is not possible.
Surrogate report of a patientʹs pain or patientʹs behavior change.
Nursing Process: Assessment
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Physiological Adaptations
4. McCaffery described a hierarchy of pain assessment techniques, including:
Patient self–report.
Search for a potential cause of a change in patient behavior.
Observation of patient behaviors when patient self–report is not possible.
Surrogate report of a patientʹs pain or patientʹs behavior change.
Nursing Process: Assessment
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 2–5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation,
pain, and delirium in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 5424) A nurse is administering haldoperidol (Haldol) IV push to a delirious patient. Which of the following is it most
important for the nurse to monitor? The patientʹs:
1. Heart rate.
2. Respiratory rate.
3. PR interval.
4. QT interval.
Answer: 4
Explanation: 1. The patient needs to be monitored for such adverse effects as QT prolongation and
dysrhythmias (torsades de pointes), which can result in sudden death, especially if the drug is
administered IV push.
Cognitive Level: Application
Nursing Process: Assessment
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. The patient needs to be monitored for such adverse effects as QT prolongation and
dysrhythmias (torsades de pointes), which can result in sudden death, especially if the drug is
administered IV push.
Cognitive Level: Application
Nursing Process: Assessment
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. The patient needs to be monitored for such adverse effects as QT prolongation and
dysrhythmias (torsades de pointes), which can result in sudden death, especially if the drug is
administered IV push.
Cognitive Level: Application
Nursing Process: Assessment
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. The patient needs to be monitored for such adverse effects as QT prolongation and
dysrhythmias (torsades de pointes), which can result in sudden death, especially if the drug is
administered IV push.
Cognitive Level: Application
Nursing Process: Assessment
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 2–5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation,
pain, and delirium in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) —CVC 12/3/08 — Page 55
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