1 of 123
Term
The nurse is caring for a 59 year old male patient who is being
treated for acute respiratory failure with bilevel positive airway
pressure (BIPAP). Which of the following nursing diagnoses would
be MOST appropriate for this patient?
Give this one a try later!
Requiring patient participation in all treatments
Feedback
The purpose of informed consent is to protect patient autonomy. Nursing staff
should encourage patient participation in decision making process regarding
treatments to avoid decreased self-esteem and increased sense of
powerlessness.
Speak with the care team and recommend referring the case to the hospital
ethics committee
Feedback
The nurse should recall that according to the AACN Synergy Model for Patient
Care, Patient Advocacy and Moral Agency means representing the concerns of
, the patient and helping to resolve ethical concerns. The correct thing to do for
the patient is to involve the hospital ethics committee.
Risk for impaired skin integrity
Feedback
The nurse should recognize that successful BIPAP therapy requires a mask
that is snugly fitted to the patient's face, which represents a threat to the
patient's skin integrity. This requires close monitoring of the patient's facial
skin to ensure that breakdown does not occur.
A 54 year old male with a BP of 153/86, and who takes metformin and simvastatin
daily
Feedback
The nurse should recall the risk factors for contrast induced nephropathy. The
patient in this scenario has three of the qualifying criteria for metabolic
syndrome, and people with metabolic syndrome are at an increased risk for
contrast induced nephropathy. Therefore, relevant protocols must be followed
when these patients undergo such testing.
Don't know?
2 of 123
Term
The nurse is providing education to a 52 year old male patient who
is newly diagnosed with type 2 diabetes. The patient tells the nurse
that he will do his best to cut down on sugary foods, but he has a
sweet tooth and doesn't think he'll be very successful. What is the
most appropriate response from the nurse?
Give this one a try later!
, Ask the provider if the patient's midnight vital signs can be skipped for the night
if the previous set are within acceptable limits
Feedback
The nurse should recall that according to the AACN Synergy Model for Patient
Care, Caring Practice involves creating a supportive and therapeutic
environment for the patient. This involves tailoring care to the needs of the
patient and not always relying on protocol to dictate the caring environment.
Asking the provider to skip the midnight vital signs is an appropriate response as
it will mean fewer interruptions to the patient's sleep.
Risk for impaired skin integrity
Feedback
The nurse should recognize that successful BIPAP therapy requires a mask that is
snugly fitted to the patient's face, which represents a threat to the patient's skin
integrity. This requires close monitoring of the patient's facial skin to ensure that
breakdown does not occur.
Begin a norepinephrine infusion with a goal MAP equal or > 65.
Feedback
The nurse should recall that norepinephrine is the recommended vasopressor of
choice for hypotensive sepsis patients who are unresponsive to fluids, and the
goal MAP is equal to or > 65.
Tell the patient that there are other healthy diet choices that can be
beneficial for diabetic patients, and ask him to set some goals for himself
related to these changes
Feedback
The nurse should recall that according to the AACN Synergy Model for
Patient Care, higher level Facilitation of Learning involves setting patient-
driven goals for education. Involving the patient in setting their own goals
improves compliance.
Don't know?
3 of 123
Term
, A 42-year-old male with Marfan syndrome and complaint of
dizziness is admitted to the telemetry unit for monitoring. Which of
the following accompanying symptoms may indicate the need for
immediate surgical attention?
A. Cough with vocal hoarseness
B. Limited rotation of the left shoulder
C.Headache that resolved after breakfast, but has returned
D. Sudden stabbing pain in the right elbow
Give this one a try later!
D. Pulsus paradoxus
Feedback
Pulsus paradoxus is defined as a drop of 10 mmHg or more in systolic blood
pressure during inspiration. Pulsus paradoxus is an indicator of cardiac
tamponade, a life-threatening complication of pericarditis. Other listed signs and
symptoms may be exhibited by a client with pericarditis with or without cardiac
tamponade.
A. Cough with vocal hoarseness
Feedback
Patients diagnosed with Marfan syndrome are at higher risk for aortic
aneurysms. Changes in vocal quality accompanied by a cough or
dysphagia (difficulty swallowing) may indicate that a thoracic aortic
aneurysm is becoming more enlarged.
C. Prepare the patient for burr hole placement with clot evacuation
Feedback
This patient is exhibiting classic signs and symptoms of an epidural hematoma.
Surgical intervention to remove the hematoma and relieve pressure on the brain
should be performed as soon as possible.
Aminoglycoside toxicity
Feedback
Term
The nurse is caring for a 59 year old male patient who is being
treated for acute respiratory failure with bilevel positive airway
pressure (BIPAP). Which of the following nursing diagnoses would
be MOST appropriate for this patient?
Give this one a try later!
Requiring patient participation in all treatments
Feedback
The purpose of informed consent is to protect patient autonomy. Nursing staff
should encourage patient participation in decision making process regarding
treatments to avoid decreased self-esteem and increased sense of
powerlessness.
Speak with the care team and recommend referring the case to the hospital
ethics committee
Feedback
The nurse should recall that according to the AACN Synergy Model for Patient
Care, Patient Advocacy and Moral Agency means representing the concerns of
, the patient and helping to resolve ethical concerns. The correct thing to do for
the patient is to involve the hospital ethics committee.
Risk for impaired skin integrity
Feedback
The nurse should recognize that successful BIPAP therapy requires a mask
that is snugly fitted to the patient's face, which represents a threat to the
patient's skin integrity. This requires close monitoring of the patient's facial
skin to ensure that breakdown does not occur.
A 54 year old male with a BP of 153/86, and who takes metformin and simvastatin
daily
Feedback
The nurse should recall the risk factors for contrast induced nephropathy. The
patient in this scenario has three of the qualifying criteria for metabolic
syndrome, and people with metabolic syndrome are at an increased risk for
contrast induced nephropathy. Therefore, relevant protocols must be followed
when these patients undergo such testing.
Don't know?
2 of 123
Term
The nurse is providing education to a 52 year old male patient who
is newly diagnosed with type 2 diabetes. The patient tells the nurse
that he will do his best to cut down on sugary foods, but he has a
sweet tooth and doesn't think he'll be very successful. What is the
most appropriate response from the nurse?
Give this one a try later!
, Ask the provider if the patient's midnight vital signs can be skipped for the night
if the previous set are within acceptable limits
Feedback
The nurse should recall that according to the AACN Synergy Model for Patient
Care, Caring Practice involves creating a supportive and therapeutic
environment for the patient. This involves tailoring care to the needs of the
patient and not always relying on protocol to dictate the caring environment.
Asking the provider to skip the midnight vital signs is an appropriate response as
it will mean fewer interruptions to the patient's sleep.
Risk for impaired skin integrity
Feedback
The nurse should recognize that successful BIPAP therapy requires a mask that is
snugly fitted to the patient's face, which represents a threat to the patient's skin
integrity. This requires close monitoring of the patient's facial skin to ensure that
breakdown does not occur.
Begin a norepinephrine infusion with a goal MAP equal or > 65.
Feedback
The nurse should recall that norepinephrine is the recommended vasopressor of
choice for hypotensive sepsis patients who are unresponsive to fluids, and the
goal MAP is equal to or > 65.
Tell the patient that there are other healthy diet choices that can be
beneficial for diabetic patients, and ask him to set some goals for himself
related to these changes
Feedback
The nurse should recall that according to the AACN Synergy Model for
Patient Care, higher level Facilitation of Learning involves setting patient-
driven goals for education. Involving the patient in setting their own goals
improves compliance.
Don't know?
3 of 123
Term
, A 42-year-old male with Marfan syndrome and complaint of
dizziness is admitted to the telemetry unit for monitoring. Which of
the following accompanying symptoms may indicate the need for
immediate surgical attention?
A. Cough with vocal hoarseness
B. Limited rotation of the left shoulder
C.Headache that resolved after breakfast, but has returned
D. Sudden stabbing pain in the right elbow
Give this one a try later!
D. Pulsus paradoxus
Feedback
Pulsus paradoxus is defined as a drop of 10 mmHg or more in systolic blood
pressure during inspiration. Pulsus paradoxus is an indicator of cardiac
tamponade, a life-threatening complication of pericarditis. Other listed signs and
symptoms may be exhibited by a client with pericarditis with or without cardiac
tamponade.
A. Cough with vocal hoarseness
Feedback
Patients diagnosed with Marfan syndrome are at higher risk for aortic
aneurysms. Changes in vocal quality accompanied by a cough or
dysphagia (difficulty swallowing) may indicate that a thoracic aortic
aneurysm is becoming more enlarged.
C. Prepare the patient for burr hole placement with clot evacuation
Feedback
This patient is exhibiting classic signs and symptoms of an epidural hematoma.
Surgical intervention to remove the hematoma and relieve pressure on the brain
should be performed as soon as possible.
Aminoglycoside toxicity
Feedback
