Test Bank For Critical Care Nursing, A Holistic Approach, 10th Edition Patricia Gonce Morton RN PhD ACNP-BC FAAN, Dorrie K. Fontaine

1.  

The critical care unit environment is very stressful for  patients, families, and staff. What nursing action is  directed at reducing environmental stress?  

A)  

Constant evaluation of patient status  

B)  

Limiting visits to immediate family  

C)  

Bathing all patients during hours of sleep  

D)  

Maintaining quiet during hours of sleep  

2.  

A patient is transferred to the ICU from the Birth Center  of the hospital in the middle of the night after  experiencing complications during delivery of her baby.  The patient’s husband is anxious and explains to the  ICU nurse that he doesn’t understand why his wife has  been moved to the ICU. “ She is going to die, isn’t  she?” he asks the nurse. What is the nurse’s best  response?  

A)  

Explain that every measure will be taken to provide  his wife with the best care possible.  

B)  

Explain that the nurse is fully trained and has years  of experience.  

C)  

Offer the husband a place to relax.  

D)  

Have appropriate staff discuss his health insurance  with him.  

3.  

A patient is admitted to the ICU with injuries sustained  from a fall from a third-story window. The patient is  conscious, his breathing is labored, and he is bleeding  heavily from the abdomen. He groans constantly and  complains of severe pain, but his movements are  minimal. His heart rate is elevated. Which of these is a  sign that he is in the second phase of the stress  response? Select all that apply.  

C)  

Severe pain  

D)  

Elevated heart rate  

E)  

Minimal movement  

4.  

A patient in the ICU is recovering from open-heart  surgery. The nurse enters his room and observes that his  daughter is performing effleurage on his arms and  talking in a low voice about an upcoming family  vacation that is planned. The room is dimly lit, and she  hears the constant beeping of his heart monitor. From  the hall she hears the cries of a patient in pain. Which of  the following are likely stressors for the patient? Select  all that apply.  

A)  

His daughter’s conversation  

B)  

His daughter’s effleurage  

C)  

The beeping of the heart monitor  

D)  

The dim lighting of the room  

E)  

The cries of the other patient from the hall  

5.  

A patient in the ICU is complaining that he is not  sleeping well at night because of anxiety. Which of the  following would be the most helpful intervention for the  nurse to make?  

A)  

Provide the patient with a bath immediately  following his first 90-minute REM sleep cycle.  

B)  

Increase the patient’s pain medication.  

C)  

Provide the patient with 5 minutes of effleurage and  then minimize disruptions.  

D)  

Monitor the patient’s brain waves by  polysomnography to determine his sleep pattern.  

B)  

Offer to come back later to perform the blood draw.  

C)  

Encourage the patient to deep breathe.  

D)  

Describe briefly the blood draw procedure and  explain why it is necessary.  

7.  

A 15-year-old boy is in the ICU and preparing for an  appendectomy. He is clearly anxious and fidgets with  his IV constantly. He complains that he doesn’t want to  be there and he is sick of everyone telling him what to  do. What would be the best way for the nurse to address  this patient’s anxiety?  

A)  

Use physical restraints to keep him from pulling out  his IV.  

B)  

Offer him the remote to the television.  

C)  

Lower the head of his bed so that he can rest more  easily.  

D)  

Explain to the patient in detail what the  appendectomy will consist of.  

8.  

A nurse in a burn unit observes that a patient is tensed  up and frowning but silent. The nurse asks the patient,  “ Can you tell me what you are thinking now?” The  patient responds, “ I can’t take this pain any more! I  feel like I’m about to die.” What would be the best  response for the nurse to give to the patient, considering  that the patient is already receiving the maximum  amount pain medication that is safe?  

A)  

“ Try to get rid of those negative thoughts—they  only make it worse.”  

B)  

“ Try thinking instead, ‘This pain will go away; I  can overcome it.’”  

C)  

“ Your pain medication is already at the highest  possible dose.”  

D)  

“ Would you like me to raise the head of your  bed?”  

A)  

Performing breathing exercises with the patient  

B)  

Offering the patient a patient-controlled analgesic  device  

C)  

Asking the physician to prescribe an antianxiety  medication  

D)  

Offering the patient the patient’s own MP3 player to  listen to  

10.  

A 10-year-old female patient in ICU receiving  chemotherapy has requested that her dog be allowed to  visit her. She is currently sharing a room with another  patient. The nurse knows that the hospital does allow  for pet visits with owners, but has strict guidelines.  Which of the following scenarios is most likely to be  permitted?  

A)  

The girl’s father may bring the dog in on a leash for  a 20-minute visit.  

B)  

The girl’s sister may bring the dog in with a shirt  on (to prevent shedding) for an overnight stay.  

C)  

The girl’s mother may bring the dog in on a leash  for a visit as long as he has had all his vaccinations.  

D)  

The dog may be brought in for a brief visit once the  girl is moved to a private room.  

11.  

The nurse understands that a patient being cared for in  a critical care unit experiences an acute stress  response. What nursing action best demonstrates  understanding of the physiological parts of the initial  stress response?  

A)  

Adequate pain control  

B)  

Intravenous sedation  

C)  

Treatment for elevated blood pressure  

D)  

Ignoring an elevated glucose level  

A)  

Helps to support the patient’s immune system  

B)  

Part of good nursing care  

C)  

Mandated by hospital policy  

D)  

Reassures the patient and family  

13.  

A patient in a critical care unit has increased stress  from the constant noise and light levels. What nursing  intervention best attenuates these sources of stress?  

A)  

Need for constant observation and evaluation  

B)  

Dimming lights during the night  

C)  

Frequent nursing group rounds for all patients  

D)  

Use of tile floors for ease in cleaning  

14.  

The nurse is caring for a patient who is orally  intubated and on a mechanical ventilator. The nurse  believes that the patient is experiencing excess  anxiety. For this patient, what behavior best indicates  anxiety?  

A)  

Restlessness  

B)  

Verbalization  

C)  

Increased respiratory rate  

D)  

Glasgow Coma Scale score of 3  

15.  

The critical care unit environment is very stressful for  patients, families, and staff. What nursing action is  directed at reducing environmental stress?  

A)  

Constant expert evaluation of patient status  

B)  

Limiting visits to immediate family  

C)  

Bathing all patients during hours of sleep  

D)  

Maintaining a quiet environment during hours of  sleep  

B)  

Hypnotic medications  

C)  

Five-minute back effleurage  

D)  

Adequate pain control  

17.  

The nurse is caring for a critically ill patient with a  very concerned family. Given that the family is under  high stress, what nursing intervention will best  ameliorate their stress while preserving independence?  

A)  

Encourage the family to participate in patient care  tasks.  

B)  

Teach the family to ask questions of the health care  team.  

C)  

Ask the family to select a family representative for  communication.  

D)  

Limit visits to immediate family members for  limited times.  

18.  

While caring for a critically ill patient, the nurse  knows that fostering patient control over the  environment is a method for stress reduction. What  nursing intervention gives the patient the most  environmental control while still adhering to best  practice principles?  

A)  

Ask the patient whether he or she wants to get out  of bed.  

B)  

Give the patient’s bath at the same time every day.  

C)  

Explain painful procedures only after giving pain  medication.  

D)  

Choose menu items for the patient to ensure a  balanced diet.  

19.  

The nurse is using presence to reduce the anxiety of a  critically ill patient. What nursing behavior  demonstrates an effective use of presence?  

A)  

Staying in the patient’s room to complete  documentation  

D)  

Focusing on specific nursing care tasks while in the  patient’s room  

20.  

The nurse is caring for a critically ill patient who can  speak. The nurse notices that the patient is  demonstrating behaviors indicative of anxiety but is  silent. What nursing strategy would give the nurse the  most information about the patient’s feelings?  

A)  

Explain procedures to the patient and family.  

B)  

Ask the patient to share his or her internal dialogue.  

C)  

Encourage the patient to nap before visiting hours.  

D)  

Ensure that the patient has adequate pain control.  

21.  

The patient is undergoing a necessary but painful  procedure that is greatly increasing her anxiety. The  nurse decides to use guided imagery to help alleviate  the patient’s anxiety. What is a key part of this  technique?  

A)  

Provide the patient with an external focus point  such as a picture.  

B)  

Have the patient take slow, shallow breaths while  staring at a focus point.  

C)  

Have the patient remember tactile sensations of a  pleasant experience.  

D)  

Encourage the patient to consciously relax all of  her muscles.  

22.  

One of the strategies shown to reduce perception of  stress in critically ill patients and their families is  support of spirituality. What nursing action is most  clearly supportive of the patient’s spirituality?  

A)  

Referring patients to the Catholic chaplain  

B)  

Providing prayer booklets to patients and families  

C)  

Asking about beliefs about the universe