Critical Care Quiz #1

Chapter 1: Professional Nursing Practice (5 Questions) Chapter 4: Adult Health and Physical Nutritional and Cultural Assessment (5 Questions) Chapter 5: Stress and Adaptation Inflammatory Response (9 Questions) Pharmacology Calculation: oral intake, ounces to cc (1 question)

Identify the BEST framework for prioritizing client problems

Maslow’s Hierarchy of Needs

1. Physiological Needs: These include basic biological needs such as food, water, shelter, and sleep.

2. Safety Needs: These involve the need for security, stability, and protection from physical and emotional harm.

3. Love and Belongingness: These refer to the need for social connections, love, friendship, and a sense of belonging.

4. Esteem and Self-Respect: These include the desire for self-esteem, recognition, respect from others, and a sense of accomplishment.

5. Self-Actualization: This is the highest level of need, representing the desire for personal growth, self-fulfillment, and reaching one's full potential.

According to Maslow, individuals must satisfy lower-level needs before progressing to higher-level needs.

Identify authorize written medical decision on behalf of a client.

• Living Will → a document used if the patient cannot make medical decisions for themselves

  • Medical Order for Life-Sustaining Treatment (MOLST) Form

    • DNR or DNI

  • Advance Directives

• Healthcare Proxy or Durable Power of Attorney → allows someone to make medical decisions on behalf if they cannot

  • NOTE: if there is no healthcare proxy or next of kin, it will be based on 2 signing physicians

Conduct a physical assessment on a client receiving prescribed opioid medication. Implement nursing action.

1. Assess vital signs! Especially beware of respiratory depression.

2. Pain assessment BEFORE administering any medication

3. Have Naloxone (Narcan) readily available

NOTE: Fentanyl patch is good for 48-72 hrs

Identify priority of nurses role when preparing a client for surgery. Focus on ethical nursing practice.

• Informed consent is obtained by the surgeon with the nurse as a witness

• Ask the patient if they understand the procedure, if there are any doubts or concerns notify the provider

• Explain to the patient how we’re going to help prepare them for surgery

Develop a care plan  and identify steps to achieve a client goal.  Refer to “ADPIE”  Nursing Process Guide

• Assessment

  • Subjective Data (chief complaint)

  • Objective Data (vitals, physical assessment)

• Diagnosis

• Plan

  • Make goals with the patient

  • Goals should relate directly to the nursing diagnoses and must be clear, specific, and measurable

  • Include the appropriate timeframe for each goal

• Intervention

  • Implementing nursing care

  • All must be patient-focused and outcome driven

• Evaluation

Identify the MOST appropriate action for the nurse when conducting a health assessment

• Establish rapport and trust

• Practice active listening and culturally sensitive body language

• Avoid medical jargon

• Be aware of nonverbal communication

• Consider patient’s educational and cultural backgrounds

• Language proficiency

• Summarize the conversation at the end and allow space for questions

Assess a client with obesity and develop a plan of care to reduce risk factors. Know BMI measurement for normal, overweight, and obesity. (SATA Question)

• Underweight BMI < 18.5

• Normal BMI 18.5 to 24.99

• Overweight BMI 25 to 29.99

• Obese BMI > 30

• Waist Circumference

  • male > 40

  • female > 35

• Complications: diabetes, delayed wound healing, cardiovascular disease, hypertension, cancer

• Interventions

  • healthy diet

  • reduce salt intake

  • regular exercise

Emphasize the nurse’s primary focus when obtaining a health history from a client.

• Patient’s chief complaint

• Comprehensive Assessment

  • Neuro

  • Cardiac

  • Respiratory

  • GI

  • GU

  • Musculoskeletal

  • Skin

• Biographical Data

• Past Medical History

• Family History

• Allergies

Conduct a nursing assessment to determine the need of a client nutritional status.

• Assess height and weight

• Check the sclera for anemia

• Capillary refill

  • normal less than 3 seconds

• Assess food record

• Assess I&O

• Assess age and gender

• Assess skin turgor for hydration status

Provide a community health teaching of the nurse’s home teaching assessment.

• Promote safety by gathering information about the home

  • Stairs? How many staircases?

  • Elevators?

  • Carpets?

  • Long cords

  • Electric stoves

  • Fire Alarms

  • Oxygen tank

Identify clinical manifestation of system’s response to stress.

• INCREASE epinephrine (adrenaline) and norepinephrine

• INCREASED vitals and metabolic rate

• High blood glucose

• INCREASED peripheral vasoconstriction (cool and clammy)

• INCREASED sodium retention

• INCREASED alertness

• INCREASED anti-inflammatory response

Conduct a nursing assessment of a client with stress response.

• Patient cannot focus

• Heart will be racing

• Mind is all over the place

Provide an appropriate nursing action for a client with anxiety. Focus on teaching back mechanism.

• Educate and instruct patients

• Assess what the patient already does or does not know

• Ask the patient to teach back the information you taught them to assess their understanding

• Decrease environmental stimulus

Assess and evaluate the components of physiologic and psychological effects on  client’s illness.

• Perform a physical assessment

  • Vitals

  • Comprehensive Assessment

• Psychosocial assessment

  • Support systems

  • Assess anxiety

  • Substance abuse

  • Assess depression

• Assess impact of stress

Define the Pathophysiology and clinical manifestation of Stress Syndrome.

• Sympathetic Nervous System

  • Fight or flight

  • INCREASE epinephrine and norepinephrine

  • INCREASE HR, BP, and RR

  • INCREASE alertness

  • Peripheral vasoconstriction → cool and clammy

  • ACTH released…

    • INCREASE blood glucose and metabolic rate

    • INCREASE sodium retention

    • INCREASE anti-inflammatory response

Identify positive and negative feedback of a client experiencing anxiety response. Focus on the client's physiologic symptoms.

• Negative Feedback

  • blood pressure regulation → BP normal or returns to normal range

  • blood glucose regulation → glucose levels normal or return to normal range after insulin

• Positive Feedback

  • BP remains high and does not return to normal

  • blood sugar remains high and does not return to normal

Identify stress and inflammatory response basis on the client’s clinical manifestation.

Patient states they feel negatively

ex. “I feel weak”, “I don’t feel like eating”, “I feel nauseous”, “I don’t have energy to move”

Define the physiologic effect of the sympathetic nervous system in response to stress.

• INCREASE epinephrine and norepinephrine

• INCREASE HR, BP, and RR

• INCREASE alertness

• INCREASE glucose and metabolic rate

• Peripheral vasoconstriction → cool and clammy

• Dilated pupils

Assess the signs and symptoms of inflammation: Follow the 5 cardinal signs.

1. Redness

2. Warmth

3. Swelling

4. Loss of function

5. Pain

Calculate oral intake ounces to cc (mL)

• 1 oz = 30 mL = 30 cc

  • ex. jello, applesauce

• 6 oz = 180 mL

  • ex. soup

• 1 cup = 8 oz = 240 mL

• 1 glass = 12 oz = 360 mL

• 1 pint = 16 oz = 480 mL