Critical-Care Nursing *Q&A* (100% Correct) 2025/2026 |VERIFIED|

Critical-Care Nursing *Q&A* (100% Correct) 2025/2026 |VERIFIED| A 65-year-old female post-operative day 2 following a hip replacement presents with confusion, fever, and hypotension. Her white blood cell count is elevated. What is the most likely cause, and what is the initial intervention? Post-operative infection (e.g., urinary tract infection or surgical site infection); start broad spectrum antibiotics and initiate cultures from appropriate sites A 50-year-old male with a history of alcohol abuse is admitted with altered mental status, agitation, and tremors. His vital signs are normal, but he has a history of delirium tremens. What is the most important treatment for this patient? Administer benzodiazepines to prevent and treat alcohol withdrawal symptoms, and monitor for seizures or further deterioration A 58-year-old male presents with acute chest pain, dyspnea, and tachycardia. His troponin levels are elevated, and an ECG shows ST elevation in the anterior leads. What is the first intervention? Administer aspirin and heparin, and prepare for immediate cardiac catheterization or thrombolysis if appropriate A 70-year-old male is admitted with acute respiratory distress syndrome (ARDS) following pneumonia. He is on mechanical ventilation with a tidal volume of 6 mL/kg of ideal body weight. What is the next step in ventilator management? Ensure lung-protective ventilation strategies, including keeping the plateau pressure below 30 cm H2O, and consider prone positioning to improve oxygenation A 48-year-old female with a history of chronic hypertension presents with severe headache, blurred vision, and chest pain. Her blood pressure is 220/120 mmHg. What is the most appropriate management? Initiate intravenous antihypertensive therapy (e.g., labetalol or nicardipine) and closely monitor for signs of end-organ damage 1 A 62-year-old male with end-stage renal disease on hemodialysis presents with nausea, vomiting, and confusion. His serum potassium is 7.5 mEq/L. What is the most critical intervention? Administer calcium gluconate to stabilize the myocardium, followed by sodium bicarbonate, insulin, and glucose to lower potassium levels A 45-year-old female is post-operative day 1 following a total abdominal hysterectomy. She develops severe abdominal pain, vomiting, and an elevated heart rate. What is the likely cause, and what should be done next? Intestinal obstruction or ileus; perform abdominal imaging and provide supportive care, including nasogastric decompression and fluid resuscitation A 60-year-old male with a history of myocardial infarction presents with signs of heart failure and a reduced ejection fraction. His vital signs are stable, but he is showing signs of congestion. What is the most important medication to initiate? Start an ACE inhibitor or ARB to reduce afterload, and consider diuretics for fluid management and symptomatic relief A 35-year-old female with lupus nephritis develops hematuria, proteinuria, and a creatinine level of 2.1 mg/dL. What is the priority treatment for this patient? Initiate corticosteroid therapy to suppress the immune response and consider immunosuppressive agents like cyclophosphamide or mycophenolate A 78-year-old male is admitted with acute-on-chronic respiratory failure due to COPD exacerbation. His ABG shows pCO2 of 55 mmHg and pO2 of 50 mmHg. What is the most appropriate intervention? Start non-invasive positive pressure ventilation (BiPAP) to assist ventilation and improve oxygenation A 53-year-old female with breast cancer presents with acute back pain, weakness, and numbness in her lower extremities. Her MRI reveals spinal cord compression. What is the first intervention? Administer high-dose corticosteroids to reduce spinal cord swelling and prepare for potential surgical decompression 2 A 45-year-old male with a history of hypertension and diabetes mellitus presents with sudden loss of vision in one eye and a headache. His blood pressure is 180/100 mmHg. What is the likely diagnosis, and what should be done next? Hypertensive retinopathy or optic neuropathy; lower blood pressure gradually with intravenous antihypertensive agents and perform a fundoscopic examination A 50-year-old female presents with decreased urine output, elevated serum creatinine, and oliguria following major abdominal surgery. What is the most likely cause, and what should be done immediately? Acute kidney injury (AKI) due to hypoperfusion; initiate intravenous fluids and consider renal replacement therapy if kidney function does not improve A 70-year-old male with a history of cirrhosis presents with increasing ascites and abdominal distension. He is at risk for spontaneous bacterial peritonitis. What is the first step in management? Initiate broad-spectrum antibiotics while awaiting ascitic fluid culture results, and consider paracentesis if necessary for diagnosis A 25-year-old male presents to the ICU following a near-drowning event. He is hypothermic and has labored breathing. What is the priority intervention? Warm the patient gradually to prevent rewarming shock and initiate mechanical ventilation if necessary for respiratory support A 60-year-old female with a history of congestive heart failure presents with severe shortness of breath, crackles on auscultation, and bilateral leg edema. What is the most likely cause, and what should be the f irst step in treatment? Acute decompensated heart failure; initiate diuretics to relieve fluid overload and improve symptoms A 30-year-old male presents with rapid onset of fever, hypotension, and petechial rash. His blood cultures grow Neisseria meningitidis. What is the priority treatment for this patient? Administer intravenous antibiotics (e.g., ceftriaxone) immediately and initiate fluid resuscitation to manage septic shock 3 A 62-year-old female post-operative day 3 following a total knee replacement develops severe shortness of breath, chest pain, and tachypnea. What is the most likely cause, and what should be done next? Pulmonary embolism; initiate anticoagulation therapy and consider thrombolysis or surgical intervention A 45-year-old male with a history of hypertension and diabetes presents with altered mental status, focal neurological deficits, and an elevated blood pressure of 200/110 mmHg. What is the most likely cause, and what is the next step in treatment? Acute hypertensive encephalopathy or stroke; initiate intravenous antihypertensives and perform a CT or MRI to assess for ischemic or hemorrhagic stroke A 58-year-old male with a history of heart failure and diabetes presents with severe shortness of breath, hypotension, and confusion. His central venous pressure (CVP) is elevated, and his cardiac output is low. What is the likely diagnosis? Cardiogenic shock; initiate inotropic support, diuretics, and consider mechanical circulatory support if necessary A 25-year-old female presents with a headache, confusion, and weakness. Her serum sodium is 118 mEq/L, and her urine osmolality is high. What is the likely diagnosis, and what should be done immediately? SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion); initiate fluid restriction and consider hypertonic saline if needed for severe symptoms A 30-year-old male presents to the ICU following a motor vehicle accident with a Glasgow Coma Scale (GCS) of 8. He has a dilated, non-reactive right pupil. What is the next priority intervention? Secure the airway and prepare for intubation to prevent further brain injury and manage potential increased intracranial pressure A 50-year-old female presents with severe abdominal pain, vomiting, and a rigid abdomen. Her white blood cell count is elevated, and her blood pressure is 90/60 mmHg. What is the likely cause, and what should be the first intervention? Peritonitis; initiate broad-spectrum antibiotics and prepare for surgical exploration if necessary 4 A 45-year-old male with a history of chronic kidney disease presents with hypertension, headaches, and blurry vision. His serum creatinine is elevated, and his urine output is reduced. What is the most likely cause, and what is the next step in management? Acute kidney injury (AKI) secondary to hypertension; initiate blood pressure control and fluid resuscitation to improve renal perfusion A 67-year-old female with diabetes mellitus and hypertension presents with sudden-onset chest pain, nausea, and sweating. Her ECG shows ST depression in the inferior leads. What is the most likely diagnosis, and what is the next step in management? Non-ST elevation myocardial infarction (NSTEMI); initiate antiplatelet therapy, heparin, and prepare for coronary angiography A 40-year-old male is admitted with severe sepsis due to a urinary tract infection. His blood pressure is 80/50 mmHg despite adequate fluid resuscitation. What is the next step in management? Administer vasopressors (e.g., norepinephrine) to maintain adequate perfusion and blood pressure A 55-year-old female presents with sudden-onset weakness and facial drooping. Her blood pressure is 200/110 mmHg, and she is alert but unable to speak. What is the most likely diagnosis, and what is the next step in treatment? Acute ischemic stroke; initiate thrombolytic therapy (tPA) if within the therapeutic window or proceed with mechanical thrombectomy if indicated A 35-year-old male presents with shortness of breath, hypoxia, and frothy sputum. He is intubated and mechanically ventilated. What is the most likely cause, and what should be done next? Acute respiratory distress syndrome (ARDS); use lung-protective ventilation strategies and optimize oxygenation with PEEP and prone positioning if indicated A 72-year-old female with a history of heart failure and diabetes presents with increased shortness of breath, orthopnea, and bilateral crackles. What is the most likely cause, and what is the first line of treatment? Acute heart failure exacerbation; initiate diuretics and optimize heart failure medications such as ACE inhibitors, beta-blockers, and aldosterone antagonists 5 A 28-year-old male presents with confusion, hallucinations, and severe hypertension. His blood pressure is 240/130 mmHg, and his serum creatinine is elevated. What is the most likely cause, and what is the next step in treatment? Hypertensive emergency, likely due to a pheochromocytoma; initiate intravenous antihypertensive therapy and further diagnostic evaluation A 50-year-old female post-operative day 3 following a C-section develops fever, abdominal pain, and an elevated white blood cell count. What is the most likely cause, and what should be done immediately? Post-operative infection; initiate broad-spectrum antibiotics and assess the surgical site for infection or abscess A 60-year-old male with a history of cirrhosis and ascites presents with worsening shortness of breath, chest pain, and a non-productive cough. His chest x-ray shows a pleural effusion. What is the likely cause, and what should be done next? Hepatic hydrothorax due to cirrhosis; perform thoracentesis to confirm diagnosis and consider paracentesis for fluid management A 45-year-old male presents with fever, night sweats, weight loss, and cough. His chest x-ray shows a cavitary lesion in the upper lung fields. What is the most likely diagnosis, and what is the next step in management? Tuberculosis; initiate anti-tuberculous therapy and ensure appropriate isolation precautions to prevent transmission A 45-year-old male presents to the ICU following a motor vehicle accident with a significant blunt abdominal trauma. His blood pressure is 90/60 mmHg, heart rate 110 bpm, and he is showing signs of oliguria. What is the most likely cause of his shock, and what is the immediate intervention? Hypovolemic shock due to internal bleeding; initiate rapid fluid resuscitation with crystalloids and prepare for possible surgical intervention A 72-year-old female with a history of chronic renal failure is admitted for an acute myocardial infarction. She has a low ejection fraction and is on hemodialysis. What is the most critical factor in managing her acute myocardial infarction? Avoiding nephrotoxic medications such as contrast agents and monitoring kidney function closely, particularly during and after any diagnostic procedures 6 A 62-year-old male with a history of chronic obstructive pulmonary disease (COPD) presents with increasing shortness of breath, hypercapnia, and respiratory acidosis. His ABG shows a pH of 7.28 and a pCO2 of 55 mmHg. What is the next best step in his management? Initiate non-invasive positive pressure ventilation (BiPAP) to assist with ventilation and reduce the work of breathing A patient who underwent a heart transplant 24 hours ago develops severe hypotension and a faint pulse. His central venous pressure (CVP) is 18 mmHg, and there is no significant change in cardiac output. What is the most likely cause of this patient's symptoms? Cardiac allograft vasculopathy, leading to transplant rejection or graft dysfunction, requiring immediate intervention and possible administration of immunosuppressive therapy A 55-year-old male post-lung transplant develops dyspnea, fever, and a cough. His chest x-ray reveals bilateral infiltrates, and his oxygen saturation is dropping despite supplemental oxygen. What is the most likely cause, and what is the next intervention? Acute pulmonary rejection or infection; initiate high-dose corticosteroids to address potential rejection or broad-spectrum antibiotics if infection is suspected A 70-year-old female presents with a recent history of falls, confusion, and hypotension. Her potassium is 2.5 mEq/L, and her ECG shows U waves and T-wave flattening. What is the most appropriate intervention for this patient? Administer intravenous potassium supplementation and correct the underlying electrolyte imbalance to prevent further arrhythmias A patient with a history of metastatic cancer presents with worsening weakness, confusion, and nausea. His calcium level is 15.2 mg/dL, and his ECG shows short QT intervals. What is the most likely cause, and what is the first-line treatment? Hypercalcemia of malignancy; administer intravenous hydration with normal saline, followed by bisphosphonates or denosumab to lower calcium levels A 30-year-old male presents with altered mental status, seizures, and hyponatremia. His serum sodium level is 118 mEq/L. What is the priority treatment for this patient, and what complications should be monitored? 7 Slow correction of sodium with hypertonic saline to avoid osmotic demyelination syndrome; closely monitor neurological status A 64-year-old male with end-stage liver disease presents with abdominal distention, jaundice, and a recent history of gastrointestinal bleeding. His INR is elevated, and his ammonia level is also elevated. What is the most likely cause of his altered mental status, and what should be done immediately? Hepatic encephalopathy due to liver failure; administer lactulose to reduce ammonia levels and correct the underlying cause of liver failure A 35-year-old female post-cesarean section develops shortness of breath, chest pain, and hypoxia. She has a history of deep vein thrombosis (DVT) and presents with elevated D-dimer levels. What is the most likely diagnosis, and what is the immediate treatment? Pulmonary embolism; initiate anticoagulation therapy and prepare for possible thrombolysis or surgical intervention if necessary A 80-year-old male with a history of hypertension presents with severe chest pain radiating to his back, a blood pressure differential of 20 mmHg between the arms, and a bruit over the abdominal aorta. What is the most likely diagnosis, and what is the next step in management? Aortic dissection; urgent imaging with CT angiography or transesophageal echocardiography to confirm diagnosis and preparation for surgical or endovascular repair A 40-year-old female is brought to the ICU following a seizure. Her serum sodium is 122 mEq/L, and her glucose is 550 mg/dL. She is diagnosed with hyperglycemic hyperosmolar syndrome (HHS). What is the priority treatment, and what complications must be monitored for? IV fluid resuscitation with isotonic saline followed by insulin infusion to reduce hyperglycemia; closely monitor for cerebral edema and electrolyte disturbances A 50-year-old male presents with fever, sore throat, and a history of recent chemotherapy. His white blood cell count is 1,000/µL, and his absolute neutrophil count (ANC) is 200/µL. What is the priority intervention? Initiate broad-spectrum intravenous antibiotics immediately to prevent or treat neutropenic fever and infection 8 A patient with a long history of type 1 diabetes mellitus presents with acute shortness of breath, hyperventilation, and a fruity odor to his breath. His blood glucose level is 600 mg/dL, and his pH is 7.18. What is the immediate treatment for this patient? Administer intravenous insulin and fluids to correct diabetic ketoacidosis (DKA) and manage electrolyte imbalances A 60-year-old male with a history of atrial fibrillation presents with sudden-onset weakness, slurred speech, and left-sided facial drooping. His CT scan shows a large ischemic stroke. What is the first step in management to minimize neurological damage? Administer thrombolytics (tPA) if within the therapeutic window, or proceed with endovascular thrombectomy if indicated A 50-year-old female with severe asthma exacerbation presents with decreased breath sounds, hyperresonance to percussion, and a respiratory rate of 36 breaths/min. What is the most likely cause of her symptoms, and what is the next step in treatment? Tension pneumothorax; perform immediate needle thoracostomy or chest tube insertion to relieve pressure and restore normal lung expansion A patient presents with a known history of chronic kidney disease (CKD) and is undergoing dialysis. They develop sudden onset of swelling in the legs, difficulty breathing, and a heart rate of 140 bpm. What is the most likely cause of these symptoms? Fluid overload due to insufficient dialysis clearance; initiate diuretics and optimize dialysis settings A 52-year-old male presents with increased confusion, tremors, and recent changes in medication for his Parkinson’s disease. His blood pressure is 150/95 mmHg, and his temperature is 103°F. What is the most likely cause, and what is the priority treatment? Neuroleptic malignant syndrome; initiate cooling measures and discontinue the offending medication immediately A 65-year-old patient with advanced chronic obstructive pulmonary disease (COPD) presents with worsening dyspnea, cyanosis, and a respiratory rate of 36 breaths/min. His ABG shows a pCO2 of 65 mmHg and a pO2 of 55 mmHg. What is the most appropriate next step in management? Start non-invasive positive pressure ventilation (BiPAP) to assist in ventilation and improve oxygenation 9 A 72-year-old female presents with sudden-onset right-sided weakness, slurred speech, and visual changes. Her CT scan reveals an ischemic stroke. She has a contraindication to thrombolytic therapy. What is the next best step in management? Consider mechanical thrombectomy if within the time window and appropriate for large vessel occlusion A 28-year-old male with a history of asthma presents with increased wheezing, coughing, and chest t ightness. His peak flow measurement is 40% of the predicted value. What is the most appropriate intervention? Administer systemic corticosteroids and inhaled bronchodilators to control the exacerbation and improve airflow Which statement best describes the concept of pain? a. Pain is an uncomfortable experience present only in the patient with an intact nervous system. b. Pain is an unpleasant experience accompanied by crying and tachycardia. c. Pain is activation of the sympathetic nervous system from an injury. d. Pain is whatever the patient experiencing it says it is, occurring when that patient says it does. ANS: D Pain is described as an unpleasant sensory and emotional experience associated with actual or potential t issue damage or described in terms of such damage. This definition emphasizes the subjective and multidimensional nature of pain. More specifically, the subjective characteristic implies that pain is whatever the person experiencing it says it is and that it exists whenever he or she says it does. What are the neural processes of encoding and processing noxious stimuli associated with pain called? a. Perception b. 10 Nociception c. Transduction d. Transmission ANS: B Nociception represents the neural processes of encoding and processing noxious stimuli necessary, but not sufficient, for pain. Transduction refers to mechanical (eg, surgical incision), thermal (eg, burn), or chemical (eg, toxic substance) stimuli that damage tissues. As a result of transduction, an action potential is produced and is transmitted by nociceptive nerve fibers in the spinal cord that reach higher centers of the brain. This is called transmission, and it represents the second process of nociception. Pain sensation transmitted by the nervous system (NS) pathway reaches the thalamus, and the pain sensation transmitted by the parasympathetic nervous system (PS) pathway reaches brainstem, hypothalamus, and thalamus. These parts of the central nervous system (CNS) contribute to the initial perception of pain. C fibers are small-diameter, unmyelinated fibers that transmit what type of pain? a. Aching b. Sharp c. Prickling d. Concentrated ANS: A C fibers are implicated in the transmission of pain described as dull, diffuse, prolonged, and delayed. Alpha fibers conduct the rapid acute pain sensation described as prickling, sharp, and fast. These fibers are activated by mechanical and thermal stimuli and are carried by the neospinothalamic tract. Which assessment findings might indicate respiratory depression after opioid administration? a. Flushed, diaphoretic skin b. Shallow respirations with a rate of 24 breaths/min 11 c. Tense, rigid posture d. Snoring Answer: D. Snoring is a warning sign. It can be a sign of respiratory depression associated with airway obstruction by the tongue, leading to hypoxemia and possibly to cardiorespiratory arrest. A patient snoring after the administration of an opioid requires the critical care nurse to observe closely. The patient is admitted to the critical care unit with hemodynamic instability and an allergy to morphine. The nurse anticipates that the practitioner will order which medication for severe pain? a. Hydromorphone b. Codeine c. Fentanyl d. Methadone Answer: C. Fentanyl is a synthetic opioid preferred for critically ill patients with hemodynamic instability or morphine allergy. Hydromorphone is a semisynthetic opioid that has an onset of action and a duration similar to those of morphine. It is more potent than morphine. Hydromorphone produces an inactive metabolite (ie, hydromorphone-3-glucuronide), making it the opioid of choice for use in patients with end-stage renal disease. Codeine has limited use in the management of severe pain. It is rarely used in critical care units. It provides analgesia for mild to moderate pain. It is usually compounded with a nonopioid. Methadone is a synthetic opioid with morphine-like properties but less sedation. It is longer acting than morphine and has a long half-life. This makes it difficult to titrate in the critical care patient Which combinations of drugs has been found to be effective in managing the pain associated with musculoskeletal and soft tissue inflammation? a. Nonsteroidal antiinflammatory drugs (NSAIDs) and opioids b. NSAIDs and antidepressants c. 12 Opioid agonists and opioid antagonists d. Adjuvants and partial agonists ANS: A The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in combination with opioids is indicated in patients with acute musculoskeletal and soft tissue inflammation. A patient underwent a thoracotomy 12 hours ago and has continuous epidural analgesia with morphine. In addition to respiratory depression, the patient should be monitored for which complications? a. Urinary retention, undue somnolence, itching, nausea, and vomiting b. Urinary incontinence, photophobia, headache, and skin rash c. Apprehension, anxiety, restlessness, sadness, anger, and myoclonus d. Gastric bleeding, nasal discharge, cerebrospinal fluid leak, and calf pain ANS: A Epidural analgesia is commonly used in critical care units after major abdominal surgery, nephrectomy, thoracotomy, and major orthopedic procedures. Monitor for adverse reactions, including respiratory depression, urinary retention, undue somnolence, itching, seizures, nausea, and vomiting. A patient underwent a thoracotomy 12 hours ago and has continuous epidural analgesia with morphine. In addition to closely monitoring the patient for side effects and complications, which intervention might enhance the patient's pain control? a. Maintain her flat in bed during the infusion. b. Position her on her right side to encourage flow of the medication across the dura. c. Limit visitors and remove any distractions such as television and music. d. 13 Consider administration of adjunct medication such as a nonsteroidal antiinflammatory agent. ANS: D Positioning will not affect medication administration, distractions such as visitors and soothing music can often enhance the effects of pharmacologic pain control, adjuvant medications can help decrease anxiety, and nonopioid analgesics can provide greater pain relief at the peripheral and central levels. Instruct and guide patient through nonpharmacologic measures (eg, relaxation therapy, guided imagery, and biofeedback) to enhance pharmacologic effectiveness. The epidural space is filled with fatty tissue and is external to the dura mater. The fatty tissue interferes with uptake, and the dura acts as a barrier to diffusion, making diffusion rate difficult to predict. Which statement accurately describes the duration of acute pain? a. Acute pain is associated with the injury to the joints and lasts about 9 months. b. Acute pain is associated with the healing process and should not exceed 6 months. c. Acute pain is persistent pain of more than 6 months after the healing process. d. Acute pain is associated with damage to the nervous system and is of infinite duration. ANS: B Acute pain has a short duration, and it usually corresponds to the healing process (30 days) but should not exceed 6 months. It implies tissue damage that is usually from an identifiable cause. If undertreated, acute pain may bring a prolonged stress response and lead to permanent damage to the patient's nervous system. In such instances, acute pain can become chronic. A patient complains of pain at his incision site. The nurse is aware that four processes are involved in nociception. In what order do the processes occur? a. Transmission, perception, modulation, and transduction b. Perception, modulation, transduction, and transmission c. Modulation, transduction, transmission, and perception 14 d. Transduction, transmission, perception, and modulation ANS: D Four processes are involved in nociception: transduction, transmission, perception, and modulation. Why use a specific pain intensity scale in the critical care unit? a. It eliminates the subjective component from the assessment. b. It focuses on the objective component of the assessment. c. It provides consistency of assessment and management. d. It provides a way to interpret physiologic indicators. ANS: C Many critical care units use a specific pain intensity scale because a single tool provides consistency of assessment, management, and documentation. A pain intensity scale is useful in the critical care environment. Asking the patient to grade his or her pain on a scale of 0 to 10 is a consistent method and aids the nurse in objectifying the subjective nature of the patient's pain. However, the patient's tool preference should be considered. The patient is sedated and breathing with the use of mechanical ventilation. The patient is unable to communicate any aspects of his pain to the nurse. What tool should the nurse use to assess the patient's pain? a. FLACC b. Wong-Baker FACES c. BIS d. BPS ANS: D 15 The BPS and the CPOT are supported by experts in critical care and are suggested for use in medical, postoperative, and nonbrain trauma critically ill adults unable to self-report in the clinical guidelines of the Society of Critical Care Medicine (SCCM). FLACC is a pediatric pain assessment tool. The Wong-Baker FACES tool requires the patient to associate a level of pain to a facial representation. BIS is as an objective measure of sedation levels during neuromuscular blockade in the critical care unit. Which of the following patients is MOST likely to be experiencing a life-threatening opioid side effect? a. Patient with respiratory rate of 10 breaths/min who is breathing deeply b. Patient with a respiratory rate of 8 breaths/min who is snoring c. Patient with blood pressure of 150/75 mm Hg and heart rate of 102 beats/min d. Patient with a temperature of 100.5° F who is asleep but easily roused ANS: B Although no universal definition of respiratory depression exists, it is usually described in terms of decreased respiratory rate (fewer than 8 or 10 breaths/min), decreased SpO2 levels, or elevated ETCO2 levels. A change in the patient's level of consciousness or snoring is a warning sign. It can be a sign of respiratory depression associated with airway obstruction by the tongue, leading to hypoxemia and possibly to cardiorespiratory arrest. A patient snoring after the administration of an opioid requires the critical care nurse to observe closely. The nurse is caring for a patient with liver dysfunction. What is the maximum dose of acetaminophen the patient should receive in 24 hours? a. 1 grams b. 2 grams c. 4 grams d. 500 milligrams ANS: B 16 Special care must be taken for patients with liver dysfunction, malnutrition, or a history of excess alcohol consumption, and their acetaminophen total dose should not exceed 2 g/day. A patient has been taking Demerol 50 mg tablets three times a day for the past 5 years for chronic back pain; however, the patient complains that the medication is not providing the same level of pain relief as it once did. Based on this statement the nurse suspects that the patient has developed what problem? a. Addiction b. Tolerance c. Physical dependence d. Physical withdrawal ANS: B The patient has developed a tolerance to the medication. Tolerance is defined as a diminution of opioid effects over time. Addiction is defined by a pattern of compulsive drug use that is characterized by an incessant longing for an opioid and the need to use it for effects other than pain relief. Physical dependence to opioids may develop if the medication is given over a long period. Physical dependence is manifested by withdrawal symptoms when the opioid is abruptly stopped The nurse is caring for a patient with a patient-controlled analgesia (PCA). The patient's spouse asks about the advantages of using this type of pain management therapy. What should the nurse say to the spouse? a. "The method allows the patient to act preemptively by administering a bolus of medication when pain begins." b. "This method allows the patient to choose between an opioid and a nonopioid medication to control pain." c. "This method decreases the risk of respiratory depression and other side effects." d. 17 "This method allows for the rise and fall of the blood level of the opioid." ANS: A The patient can self-administer a bolus of medication the moment the pain begins, acting preemptively. Allowing the patient to self-administer opioid doses does not diminish the role of the critical care nurse in pain management. The nurse advises about necessary changes to the prescription and continues to monitor the effects of the medication and doses. The patient is closely monitored during the first 2 hours of therapy and after every change in the prescription. If the patient's pain does not respond within the f irst 2 hours of therapy, a total reassessment of the pain state is essential. If the patient is pressing the button to bolus medication more often than the prescription, the dose may be insufficient to maintain pain control. Naloxone must be readily available to reverse adverse opiate respiratory effects. Relaxation, distraction, guided imagery, and music therapy are all examples what type of pain management? a. Physical techniques b. Cognitive-behavioral techniques c. Nonopioid analgesia d. Equianalgesia ANS: B Using the cortical interpretation of pain as the foundation, several interventions can reduce the patient's pain report. These modalities include cognitive techniques such as relaxation, distraction, guided imagery, and music therapy The patient has received ketamine for its analgesic effects. The patient suddenly states, "I feel like I am f loating and can see everything you are doing. I am not in control." What is this response called? a. Hallucination state b. Guided imagery c. Dissociative state 18 d. Adverse event ANS: C Before administering ketamine, the dissociative state should be explained to the patient. Dissociative state refers to the feelings of separateness from the environment, loss of control, hallucinations, and vivid dreams. The use of benzodiazepines (eg, midazolam) can reduce the incidence of this unpleasant effect. A nurse is administering naloxone to a patient experiencing respiratory depression. Which of the following interventions must be observed when using naloxone? (Select all that apply.) a. Naloxone is normally given rapidly via IV. b. Naloxone is discontinued as soon as a patient is responsive to physical stimulation and able to take deep breaths. c. Naloxone has a shorter duration than most opioids, so the nurse may need to repeat naloxone as early as 30 minutes after the first dose. d. The patient's pain control is easily established after receiving naloxone. e. Naloxone is not recommended after prolonged analgesia because it can induce withdrawal and may cause nausea and dysrhythmias. ANS: B, C, D Naloxone is normally given intravenously very slowly (0.5 mL over 2 minutes) while the patient is carefully monitored for reversal of the respiratory signs. Naloxone administration can be discontinued as soon as the patient is responsive to physical stimulation and able to take deep breaths. However, the medication should be kept nearby. Because the duration of naloxone is shorter than most opioids, another dose of naloxone may be needed as early as 30 minutes after the first dose. The benefits of reversing respiratory depression with naloxone must be carefully weighed against the risk of a sudden onset of pain and the difficulty achieving pain relief. To prevent this from occurring, it is important to provide a nonopioid medication for pain relief. Moreover, the use of naloxone is not recommended after prolonged analgesia because it can induce withdrawal and may cause nausea and cardiovascular complications (eg, dysrhythmias). Which statements are true regarding pain assessment and management? (Select all that apply.) 19 a. The single most important assessment tool available to the nurse is the patient's self-report. b. The only way to assess pain in patients unable to verbalize because of mechanical ventilation is through observation of behavioral indicators. c. The concept of equianalgesia uses morphine as a basis for dosage comparison for other medications. d. Transcutaneous electrical nerve stimulation and application of heat or cold therapy stimulate the nonpain sensory fibers. e. ANS: A, C, D Meperidine, a synthetic form of morphine, is much stronger and is given at lower doses at less frequent intervals. Appropriate pain assessment is the foundation of effective pain treatment. Because pain is recognized as a subjective experience, the patient's self-report is considered the most valid measure for pain and should be obtained as often as possible. Unfortunately, in critical care, many factors, such as the administration of sedative agents, the use of mechanical ventilation, and altered levels of consciousness, may impact communication with patients. These obstacles make pain assessment more complex. Meperidine (Demerol) is a less potent opioid with agonist effects similar to those of morphine. It is considered the weakest of the opioids, and it must be administered in large doses to be equivalent in action to morphine. Because the duration of action is short, dosing is frequent. Equianalgesic means approximately the same pain relief. Dosages in the equianalgesic chart for moderate to severe pain are not necessarily starting doses. The doses suggest a ratio for comparing the analgesia of one medication with another. To achieve ventilator synchrony in a mechanically ventilated patient with acute respiratory distress syndrome (ARDS), which level of sedation might be most effective? a. Light b. Moderate c. Conscious d. 20 Deep ANS: D Deep sedation is used when the patient must be unresponsive to deliver necessary care safely. A patient has been taking benzodiazepines and suddenly develops respiratory depression and hypotension. After careful assessment, the nurse determines that the patient is experiencing benzodiazepine overdose. What is the nurse's next action? a. Decrease benzodiazepines to half the prescribed dose. b. Increase IV fluids to 500 cc/h for 2 hours. c. Administer flumazenil (Romazicon). d. Discontinue benzodiazepine and start propofol. ANS: C The major unwanted side effects associated with benzodiazepines are dose-related respiratory depression and hypotension. If needed, flumazenil (Romazicon) is the antidote used to reverse benzodiazepine overdose in symptomatic patients. A patient is admitted unit with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high pressure alarm on the ventilator has been frequently triggered. What action should be the nurse take f irst? a. Administer midazolam 5 mg by intravenous push immediately. b. Assess the patient to see if a physiologic reason exists for his agitation. c. Obtain an arterial blood gas level to ensure the patient is not hypoxemic. d. Apply soft wrist restraints to keep him from pulling out the endotracheal tube. ANS: B 21 The first step in determining the need for sedation is to assess the patient quickly for any physiologic causes that can be quickly reversed. In this case, endotracheal suctioning may solve the high-pressure alarm problem. A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. The patient continues to be very agitated, and the nurse can find nothing physiologic to account for the high-pressure alarm. What action should the nurse take next? a. Administer midazolam 5 mg by intravenous push immediately. b. Eliminate noise and other stimuli in the room and speak softly and reassuringly to the patient. c. Obtain an arterial blood gas to ensure the patient is not becoming more hypoxemic. d. Call the respiratory care practitioner to replace the malfunctioning ventilator. ANS: B Optimizing the environment, speaking calmly, explaining things to the patient, and providing distractions are all nonpharmacologic means to decrease anxiety. A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. Despite the nurse's actions, the patient continues to be agitated, triggering the high-pressure alarm on the ventilator. Which medication would be appropriate to sedate the patient this time? a. Midazolam 2 to 5 mg intravenous push (IVP) every 5 to 15 minutes until the patient is no longer triggering the alarm b. Haloperidol 5 mg IVP stat c. Propofol 5 mcg/kg/min by IV infusion d. 22 Fentanyl 25 mcg IVP over a 15-minute period ANS: A Midazolam is the recommended drug for use in alleviating acute agitation. Propofol can be used for short- and intermediate-term sedation. Haloperidol is indicated for dementia. Fentanyl is a narcotic and is not appropriate for use as a sedative. A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient had become very agitated and required some sedation. After the patient's agitation is controlled, which medications would be most appropriate for long-term sedation? a. Morphine 2 mg/h continuous IV drip b. Haloperidol 15 mcg/kg/min continuous IV infusion c. Propofol 5 mcg/kg/min by IV infusion d. Lorazepam 0.01 to 0.1 mg/kg/h by IV infusion ANS: D Propofol may be used for ongoing sedation for short- and intermediate-term sedation (1-3 days) and should be coupled with a short-acting opioid analgesic. Morphine is an opioid analgesic and is not sedation. Lorazepam infusion (0.01-0.1 mg/kg/h) is recommended for long-term sedation. When administering propofol over an extended period, what laboratory value should the nurse routinely monitor? a. Serum triglyceride level b. Sodium and potassium levels c. Platelet count d. Acid-base balance ANS: A 23 Prolonged use of propofol may cause an elevated triglyceride level because of its high lipid content. What is a major side effect of benzodiazepines? a. Hypertension b. Respiratory depression c. Renal failure d. Phlebitis ANS: B The major side effects of benzodiazepines include hypotension and respiratory depression. These side effects are dose related. What is the major advantage of using propofol as opposed to another sedative for short-term sedation? a. Fewer side effects b. Slower to cross the blood-brain barrier c. Shorter half-life and rapid elimination rate d. Better amnesiac properties ANS: C Propofol is an effective short-term anesthetic agent, useful for rapid "wake-up" of patients for assessment; if continuous infusion is used for many days, emergence from sedation can take hours or days; sedative effect depends on the dose administered, depth of sedation, and length of time sedated. Which of the following medications is used for sedation in patients experiencing withdrawal syndrome? a. Dexmedetomidine 24 b. Hydromorphone c. Diazepam d. Clonidine ANS: D Clonidine (often prescribed as a Catapres patch) is a central a-agonist and is recommended for sedation during withdrawal syndrome. A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the bedding. The nurse suspects the patient may be experiencing what issue? a. Delirium b. Hypoxemia c. Hypocalcemia d. Sedation withdrawal ANS: A Delirium is represented by a global impairment of cognitive processes, usually of sudden onset, coupled with disorientation, impaired short-term memory, altered sensory perceptions (hallucinations), abnormal thought processes, and inappropriate behavior. There is no evidence provided that would indicate the patient is hypoxemic, hypocalcemic, or going through sedation withdrawal. A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the bedding. What is the medication of choice for treating this patient? a. Diazepam b. 25 Haloperidol c. Lorazepam d. Propofol ANS: B Haloperidol is the drug of choice when treating delirium. Lorazepam has been associated with an increased incidence of delirium. Propofol is indicated for sedation use. Diazepam is not an appropriate choice for this patient. A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the bedding. What parameter should be monitored while the patient is haloperidol? a. Sedation level b. QTc-interval c. Oxygen saturation level d. Brain waves ANS: B Electrocardiogram (ECG) monitoring is recommended because haloperidol use can produce dose dependent QTc-interval prolongation, with an increased incidence of ventricular dysrhythmias. BIS monitoring is indicated for deep sedation use. What is the most common contributing factor to the development of delirium in critically ill patients? a. Sensory overload b. Hypoxemia c. Electrolyte disturbances 26 d. Sleep deprivation ANS: D Delirium is frequently associated with critical illness. Provision of adequate sleep and early mobilization are recommended to reduce the incidence of delirium. Which medication has a greater advantage for treatment of alcohol withdrawal syndrome (AWS) because of its longer half-life and high lipid solubility? a. Lorazepam b. Midazolam c. Propofol d. Diazepam ANS: D Management of alcohol withdrawal involves close monitoring of AWS-related agitation and administration of IV benzodiazepines, generally diazepam (Valium) or lorazepam (Ativan). Diazepam has the advantage of a longer half-life and high lipid solubility. Lipid-soluble medications quickly cross the blood-brain barrier and enter the central nervous system to rapidly produce a sedative effect. Midazolam is the recommended drug for use in alleviating acute agitation but is known to cause seizures with AWS because of rapid withdrawal. Propofol is indicated for sedation use. What are the risk factors for delirium? a. Hypertension, alcohol abuse, and benzodiazepine administration b. Coma, hypoxemia, and trauma c. Dementia, hypertension, and pneumonia d. Coma, alcohol abuse, hyperglycemia ANS: A 27 Risk factors for delirium risk include dementia, hypertension, alcohol abuse, high severity of illness, coma, and benzodiazepine administration. What are the two scales that are recommended for assessment of agitation and sedation in adult critically ill patients? a. Ramsay Scale and Riker Sedation-Agitation Scale (SAS) b. Ramsay Scale and Motor Activity Assessment Scale (MAAS) c. Riker Sedation-Agitation Scale (SAS) and the Richmond Agitation-Sedation Scale (RASS) d. Richmond Agitation-Sedation Scale (RASS) and Motor Activity Assessment Scale (MAAS) ANS: C The two scales that are recommended for assessment of agitation and sedation in adult critically ill patients are the SAS and the RASS. Which intervention is an effective nursing strategy to decrease the incidence of delirium? a. Restriction of visitors b. Early nutritional support c. Clustering of nursing care activities d. Bedrest ANS: C As lack of sleep is a major contributor to the development of delirium, interventions to promote sleep should help decrease the incidence of delirium. Some critical care units have initiated sleep protocols to increase the opportunity for patients to sleep at night, dimming lights at night, ensuring there are periods of time when tubes are not manipulated, and clustering nursing care interventions to provide some uninterrupted rest periods. Early ambulation is also appropriate. 28 What are the causes of delirium in critically ill patients? (Select all that apply.) a. Hyperglycemia b. Meningitis c. Cardiomegaly d. Pulmonary embolism e. Alcohol withdrawal syndrome f. Hyperthyroidism B, E, F The causes of delirium in critically ill patients include metabolic causes (acid-base disturbance, electrolyte imbalance, hypoglycemia), intracranial causes (epidural or subdural hematoma, intracranial hemorrhage, meningitis, encephalitis, cerebral abscess, tumor), endocrine causes (hyperthyroidism or hypothyroidism, Addison disease, hyperparathyroidism, Cushing syndrome), organ failure (liver encephalopathy, kidney encephalopathy, septic shock), respiratory causes (hypoxemia, hypercarbia), and medication-related causes (alcohol withdrawal syndrome, benzodiazepines, heavy metal poisoning). Which complications can result from prolonged deep sedation? (Select all that apply.) a. Pressure ulcers b. Thromboembolism c. Diarrhea d. Nosocomial pneumonia e. 29 Delayed weaning from mechanical ventilation f. Hypertension ANS: A, B, D, E Oversedation can result in a multitude of complications. Prolonged deep sedation is associated with significant complications of immobility, including pressure ulcers, thromboembolism, gastric ileus, nosocomial pneumonia, and delayed weaning from mechanical ventilation. Which of the following statements about comfort care is accurate? a. Withholding and withdrawing life-sustaining treatment are distinctly different in the eyes of the legal community. b. Each procedure should be evaluated for its effect on the patient's comfort before being implemented. c. Only the patient can determine what constitutes comfort care for him or her. d. Withdrawing life-sustaining treatments is considered euthanasia in most states. ANS: B The goal of comfort care is to provide only treatments that do not cause pain or other discomfort to the patient What is a powerful influence when the decision-making process is dealing with recovery or a peaceful death? a. Hope b. Religion c. Culture d. Ethics ANS: A 30 Hope is a powerful influence on decision making, and a shift from hope for recovery to hope for a peaceful death should be guided by clinicians with exemplary communication skills. Ethics, religion, and culture can influence the decision process regarding care and end-of-life decisions. The patient's condition has deteriorated to the point where she can no longer make decisions about her own care. Which nursing interventions would be most appropriate? a. Obtain a verbal do-not-resuscitate (DNR) order from the practitioner. b. Continue caring for the patient as originally ordered because she obviously wanted this. c. Consult the hospital attorney for recommendations on how to proceed. d. Discuss with the family what the patient's wishes would be if she could make those decisions herself. ANS: D If the patient is not able to make end-of-life decisions for herself, her family members should be approached to discuss the next steps because they may have insight into what her wishes would be. What are the two basic ethical principles underlying the provision of health care? a. Beneficence and nonmaleficence b. Veracity and beneficence c. Fidelity and nonmaleficence d. Veracity and fidelity ANS: A The two basic ethical principles underlying the provision of health care are beneficence and nonmaleficence. 31 A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The patient does not have an advance directive. Which statement would be the best way to approach the family regarding his ongoing care? a. "I will refer this case to the hospital ethics committee, and they will contact you when they have a decision." b. "What do you want to do about the patient's care at this point?" c. "Dr. Smith believes that there is no hope at this point and recommends do-not-resuscitate status." d. "What would the patient want if he knew he were in this situation?" ANS: D Approaching the family and asking what they know about the patient's wishes and preferences is the best way to begin this discussion. Emotional support for the patient and the family is important as they discuss advance care planning in the critical care setting. A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. After a family conference, the practitioner orders a do-not-resuscitate (DNR) order, and palliative care is begun. How does this affect the patient's treatment? a. The patient will continue to receive the same aggressive treatment short of resuscitation if he has another cardiac arrest. b. All treatment will be stopped, and the patient will be allowed to die. c. All attempts will be made to keep the patient comfortable without prolonging his life. d. The patient will be immediately transferred to hospice. ANS: C 32 When palliative care is begun, the primary goal is to keep the patient comfortable by continuing assessments and managing symptoms that might cause pain, anxiety, or distress. A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The patient is placed on a morphine drip to alleviate suspected operative pain and assist in sedation. The patient continues to grimace and fight the ventilator. What nursing intervention would be appropriate? a. Increase the morphine dosage until no signs of pain or discomfort are present. b. Increase the morphine drip, but if the patient's respiratory rate drops below 10 breaths/min, return to the original dosage. c. Gradually decrease the morphine and switch to Versed to avoid respiratory depression. d. Ask the family to leave the room because their presence is causing undue stress to the patient. ANS: A Even though opiates can cause respiratory depression, the goal in palliative care is to alleviate pain and suffering. A bolus dose of morphine (2-10 mg IV) and a continuous morphine infusion at 50% of the bolus dose per hour is recommended. Because many critical care patients are not conscious, assessment of pain and other symptoms becomes more difficult. Gélinas and colleagues recommended using signs of body movements, neuromuscular signs, facial expressions, or responses to physical examination for pain assessment in patients with altered consciousness. A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The decision is made to remove the patient from the ventilator. Which of the following statements is most accurate? a. The cardiac monitor should be left on so everyone will know when the patient has died. b. Opioids, sedatives, and neuromuscular blocking agents should be discontinued just before removing the ventilator. 33 c. The family and health care team should decide the best method for removing the ventilator terminal wean versus immediate extubation. d. If terminal weaning is selected, the family should be sent to the waiting room until the ventilator has actually been removed. ANS: C The choice of terminal wean as opposed to extubation is based on considerations of access for suctioning, appearance of the patient for the family, how long the patient will survive off the ventilator, and whether the patient has the ability to communicate with loved ones at the bedside. A patient was admitted to the critical care unit after having a cerebrovascular accident (CVA) and myocardial infarction (MI). The patient has poor activity tolerance, falls in and out of consciousness, and has poor verbal skills. The patient has been resuscitated four times in the past 6 hours. The patient does not have advance directives. Family members are at the bedside. Who should the practitioner approach to discuss decisions of care and possible do-not-resuscitate (DNR) status? a. Patient b. Family c. Hospital legal system d. Hospital ethics committee ANS: A Patients' capacity for decision making is limited by illness severity; they are too sick or are hampered by the therapies or medications used to treat them. When decision making is required, the patient is the f irst person to be approached. Which statement regarding organ donation is accurate? a. Organ donation is a choice only the patient can make for him- or herself. b. Hospitals must have written protocols for the identification of potential organ donors. 34 c. Organ donation must be requested by the nurse caring for the dying patient. d. Individual institutional policies govern how organ donation requests are made. ANS: B The Social Security Act Section 1138 requires that hospitals have written protocols for the identification of potential organ donors. The Joint Commission has a standard on organ donation. The nurse must notify the organ procurement official to approach the family with a donation request. Hospice care is an option that should be considered, especially in end-stage illness. Hospice care can help families with which issue(s)? a. Organ and tissue donations b. Symptom management and family support c. Procurement of advance directives and living wills d. Legal and voluntary euthanasia ANS: B Health professionals can assist patients and families by providing information about the hospice benefit, particularly regarding the aggressive symptom management and family support. Organ donations must follow Social Security Act Section 1138 regarding written protocols for identification of potential organ donors and notification of organ recovery agencies. Advance directives can be taken care of at the hospital or legal firm. Euthanasia generally not offered through hospice. Disagreement and distress among practitioners, nurse practitioners, and critical care nurses can lead to what issue? a. Moral indignation b. Ethical resentment c. 35 Moral distress d. Interprofessional anguish ANS: C Nurses and doctors frequently disagree about the futility of interventions. Sometimes nurses consider withdrawal before practitioners and patients do, and they then believe the care they are giving is unnecessary and possibly harmful. This issue is a serious one for critical care nurses because moral distress can lead to burnout. In caring for a patient receiving palliative care, antiemetics are used in the treatment of what problem? a. Dyspnea b. Nausea and vomiting c. Anxiety d. Edema ANS: B Nausea and vomiting are common and should be treated with antiemetics. Dyspnea is best managed with close evaluation of the patient and the use of opioids, sedatives, and nonpharmacologic interventions (oxygen, positioning, and increased ambient air flow). Benzodiazepines, especially midazolam with its rapid onset and short half-life, are frequently used to treat anxiety. Haloperidol are traditionally been used to managed which symptom? a. Anxiety b. Dyspnea c. Delirium d. Pain ANS: C 36 Delirium is commonly observed in critically ill patients and in those approaching death. Haloperidol and benzodiazepines (such as midazolam, lorazepam) have traditionally been used to manage delirium but have side effects that can be problematic. More recently, atypical antipsychotics have proven equally effective without troubling side effects of other drug classes. Dyspnea is best managed with close evaluation of the patient and the use of opioids, sedatives, and nonpharmacologic interventions (oxygen, positioning, and increased ambient air flow). Benzodiazepines, especially midazolam with its rapid onset and short half-life, are frequently used to treat anxiety. Morphine is the most common drug used for pain management. A patient tells the nurse to call his family and tell them they need to come so they can say their goodbyes. The patient is sure he will not be here tomorrow because his grandparent is waiting for him. What is the patient exhibiting? a. Anxiety b. Delirium c. Metabolic derangement d. Near-death awareness ANS: D The same behaviors may be seen in conscious critical care patients near death. Having an awareness of the phenomenon enables more careful assessment of behaviors that may be interpreted as delirium, acid-base imbalance, or other metabolic derangements. These behaviors include communicating with someone who is not alive, preparing for travel, describing a place the patient can see, or even knowing when death will occur. Recommendations for creating a supportive atmosphere during end-of-life discussions include which intervention? a. Telling the family when and where the procedure will occur b. Beginning the conversation by inquiring about the emotional state of the family c. Ending the conversation by inquiring about the emotional state of the family 37 d. Recommendations that the family not be present when the procedure occurs ANS: B Recommendations for creating a supportive atmosphere during withdrawal discussions include taking a moment at the beginning of the conversation to inquire about the family's emotional state. During the family meeting in which a decision to withdraw life support is made, a time to initiate withdrawal is usually established. What is the most common complaint heard from families of dying patients? a. Poor nursing care b. Inadequate communication c. Lack of consistent plan of care d. Confusion among health care team members ANS: B Communication seems to be the most common source of complaints in families across studies and should be at the center of efforts to improve end-of-life care. Families have commonly complained about infrequent physician communication, unmet communication needs in the shift from aggressive to end of-life care, and lacking or inadequate communication. Which of the following are considerations when making the decision to allow family at the bedside during resuscitation efforts? (Select all that apply.) a. The patient's wishes b. Experience of the staff c. The family's need to participate in all aspects of the patient's care d. State regulatory issues 38 e. Seeing the resuscitation may confirm the impact of decisions made or delayed ANS: A, B, C, E The decision to allow family members at the bedside during resuscitative efforts should be made by the family and caregivers and be based on needs and experiences. The family may become more aware of what is involved in decisions if they ar