CHAMBERLAIN COLLEGE OF NURSING: COMPLEX CRITICAL NURSING 341 TEST 1. 100% CORRECT

1. Which of the following professional organizations best supports critical care nursing practice? a. American Association of Critical-Care Nurses b. American Heart Association c. American Nurses Association d. Socie ...

1. Which of the following professional organizations best supports critical care nursing practice? a. American Association of Critical-Care Nurses b. American Heart Association c. American Nurses Association d. Society of Critical Care Medicine ANS: A The American Association of Critical-Care Nurses is the specialty organization that supports and represents critical care nurses. The American Heart Association supports cardiovascular initiatives. The American Nurses Association supports all nurses. The Society of Critical Care Medicine represents the multiprofessional critical care team under the direction of an intensivist. 2. A nurse has been working as a staff nurse in the surgical intensive care unit for 2 years and is interested in certification. Which credential would be most applicable for her to seek? a. ACNPC b. CCNS c. CCRN d. PCCN ANS: C The CCRN certification is appropriate for nurses in bedside practice who care for critically ill patients. The ACNPC certification is for acute care nurse practitioners. The CCNS certification is for critical care clinical nurse specialists. The PCCN certification is for staff nurses working in progressive care, intermediate care, or step-down unit settings. 3. The main purpose of certification is to: a. assure the consumer that you will not make a mistake. b. prepare for graduate school. c. promote magnet status for your facility. d. validate knowledge of critical care nursing. ANS: D Certification assists in validating knowledge of the field, promotes excellence in the profession, and helps nurses to maintain their knowledge of critical care nursing. Certification helps to assure the consumer that the nurse has a minimum level of knowledge; however, it does not ensure that care will be mistake-free. Certification does not prepare one for graduate school; however, achieving certification demonstrates motivation for achievement and professionalism. Magnet facilities are rated on the number of certified nurses; however, that is not the purpose of certification. 4. The synergy model of practice focuses on: a. allowing unrestricted visiting for the patient 24 hours each day. b. holistic and alternative therapies. c. needs of patients and their families, which drives nursing competency. d. patients’ needs for energy and support. ANS: C The synergy model of practice states that the needs of patients and families influence and drive competencies of nurses. Nursing practice based on the synergy model would involve tailored visiting to meet the patient’s and family’s needs and application of alternative therapies if desired by the patient, but that is not the primary focus of the model. 5. The family of your critically ill patient tells you that they have not spoken with the physician in over 24 hours and they have some questions that they want clarified. During morning rounds, you convey this concern to the attending intensivist and arrange for her to meet with the family at 4:00 PM in the conference room. Which competency of critical care nursing does this represent? a. Advocacy and moral agency in solving ethical issues b. Clinical judgment and clinical reasoning skills c. Collaboration with patients, families, and team members d. Facilitation of learning for patients, families, and team members ANS: C Although one might consider that all of these competencies are being addressed, communication and collaboration with the family and physician best exemplify the competency of collaboration. 6. The AACN Standards for Acute and Critical Care Nursing Practice use what framework to guide critical care nursing practice? a. Evidence-based practice b. Healthy work environment c. National Patient Safety Goals d. Nursing process ANS: D The AACN Standards for Acute and Critical Care Nursing Practice delineate the nursing process as applied to critically ill patients: collect data, determine diagnoses, identify expected outcomes, develop a plan of care, implement interventions, and evaluate care. AACN promotes a healthy work environment, but this is not included in the Standards. The Joint Commission has established National Patient Safety Goals, but these are not the AACN Standards. 7. The charge nurse is responsible for making the patient assignments on the critical care unit. She assigns the experienced, certified nurse to care for the acutely ill patient with sepsis who also requires continuous renal replacement therapy and mechanical ventilation. She assigns the nurse with less than 1 year of experience to two patients who are more stable. This assignment reflects implementation of the: a. crew resource management model b. National Patient Safety Goals c. Quality and Safety Education for Nurses (QSEN) model d. synergy model of practice ANS: D This assignment demonstrates nursing care to meet the needs of the patient. The synergy model notes that the nurse competencies are matched to the patient characteristics. Crew resource management concepts related to team training, National Patient Safety Goals are specified by The Joint Commission to promote safe care but do not incorporate the synergy model. The Quality and Safety Education for Nurses initiative involves targeted education to undergraduate and graduate nursing students to learn quality and safety concepts. 8. The vision of the American Association of Critical-Care Nurses is a healthcare system driven by: a. a healthy work environment. b. care from a multiprofessional team under the direction of a critical care physician. c. the needs of critically ill patients and families. d. respectful, healing, and humane environments. ANS: C The AACN vision is a healthcare system driven by the needs of critically ill patients and families where critical care nurses make their optimum contributions. AACN promotes initiatives to support a healthy work environment as well as respectful and healing environments, but that is not the organization’s vision. The SCCM promotes care from a multiprofessional team under the direction of a critical care physician. 9. The most important outcome of effective communication is to: a. demonstrate caring practices to family members. b. ensure that patient teaching is done. c. meet the diversity needs of patients. d. reduce patient errors. ANS: D Many errors are directly attributed to faulty communication. Effective communication has been identified as an essential strategy to reduce patient errors and resolve issues related to patient care delivery. Communication may demonstrate caring practices, be used for patient/family teaching, and address diversity needs; however, the main outcome of effective communication is patient safety. 10. You are caring for a critically ill patient whose urine output has been low for 2 consecutive hours. After a thorough patient assessment, you call the intensivist with the following report. Dr. Smith, I’m calling about Mrs. P., your 65-year-old patient in CCU 10. Her urine output for the past 2 hours totaled only 40 mL. She arrived from surgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the past 2 hours, her heart rate has increased from 80 to 100 beats per minute and her blood pressure has decreased from 128/82 to 100/70 mm Hg. She is being given an infusion of normal saline at 100 mL per hour. Her right atrial pressure through the subclavian central line is low at 3 mm Hg. Her urine is concentrated. Her BUN and creatinine levels have been stable and in normal range. Her abdominal dressing is dry with no indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider increasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the information the nurse gives about the patient’s history and vital signs is: a. Situation b. Background c. Assessment d. Recommendation ANS: B The history and vital signs are part of the background. Information regarding the low urine output is the situation. Information regarding possible hypovolemia is part of the nurse’s assessment, and the suggestion for fluids is the recommendation. 11. The family members of a critically ill, 90-year-old patient bring in a copy of the patient’s living will to the hospital, which identifies the patient’s wishes regarding health care. You discuss contents of the living will with the patient’s physician. This is an example of implementation of which of the AACN Standards of Professional Performance? a. Acquires and maintains current knowledge of practice b. Acts ethically on the behalf of the patient and family c. Considers factors related to safe patient care d. Uses clinical inquiry and integrates research findings in practice ANS: B Discussing end-of-life issues is an example of a nurse acting ethically on behalf of the patient and family. The example does not relate to acquiring knowledge, promoting patient safety, or using research in practice. 12. Which of the following assists the critical care nurse in ensuring that care is appropriate and based on research? a. Clinical practice guidelines b. Computerized physician order entry c. Consulting with advanced practice nurses d. Implementing Joint Commission National Patient Safety Goals ANS: A Clinical practice guidelines are being implemented to ensure that care is appropriate and based on research. Some physician order entry pathways, but not all, are based on research recommendations. Some advanced practice nurses, but not all, are well versed in evidence-based practices. The National Patient Safety Goals are recommendations to reduce errors using evidence-based practices. 13. Comparing the patient’s current (home) medications with those ordered during hospitalization and communicating a complete list of medications to the next provider when the patient is transferred within an organization or to another setting are strategies to: a. improve accuracy of patient identification. b. prevent errors related to look-alike and sound-alike medications. c. reconcile medications across the continuum of care. d. reduce harms associated with administration of anticoagulants. ANS: C These are steps recommended in the National Patient Safety Goals to reconcile medications across the continuum of care. Improving accuracy of patient identification is another National Patient Safety Goal. Preventing errors related to look-alike and sound-alike medications is done to improve medication safety, not medication reconciliation. Reducing harms associated with administration of anticoagulants is another National Patient Safety Goal. 14. As part of nursing management of a critically ill patient, orders are written to keep the head of the bed elevated at 30 degrees, awaken the patient from sedation each morning to assess readiness to wean from mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a group to reduce the risk of ventilator-associated pneumonia. This group of evidence-based interventions is often called a: a. bundle of care. b. clinical practice guideline. c. patient safety goal. d. quality improvement initiative. ANS: A A group of evidence-based interventions done as a whole to improve outcomes is termed a bundle of care. This is an example of the ventilator bundle. Oftentimes these bundles are derived from clinical practice guidelines and are monitored for compliance as part of quality improvement initiatives. At some point, these may become part of patient safety goals. 15. You work in an intermediate care unit that has experienced high nursing turnover. The nurse manager is often considered to be an autocratic leader by staff members and her leadership style is contributing to turnover. You have asked to be involved in developing new guidelines to prevent pressure ulcers in your patient population. The nurse manager tells you that you do not yet have enough experience to be on the prevention task force. This situation and setting is an example of: a. a barrier to handoff communication. b. a work environment that is unhealthy. c. ineffective decision making. d. nursing practice that is not evidence-based. ANS: B These are examples of an unhealthy work environment. A healthy work environment values communication, collaboration, and effective decision making. It also has authentic leadership. It is not an example of handoff communication, which is communication that occurs to transition patient care from one staff member to another. Neither does it relate to ineffective decision making. As a nurse, you can still implement evidence-based practice, but your influence in the unit is limited by the unhealthy work environment. 16. Which of the following statements describes the core concept of the synergy model of practice? a. All nurses must be certified in order to have the synergy model implemented. b. Family members must be included in daily interdisciplinary rounds. c. Nurses and physicians must work collaboratively and synergistically to influence care. d. Unique needs of patients and their families influence nursing competencies. ANS: D The synergy model of practice is care based on the unique needs and characteristics of the patient and family members. Although critical care certification is based on the synergy model, the model does not specifically address certification. Inclusion of family members into the daily rounds is an example of implementation of the synergy model. With the focus on patients and family members with nurse interaction, the synergy model does not address physician collaboration. 17. A nurse who plans care based on the patient’s gender, ethnicity, spirituality, and lifestyle is said to: a. be a moral advocate. b. facilitate learning. c. respond to diversity. d. use clinical judgment. ANS: C Response to diversity considers all of these aspects when planning and implementing care. A moral agent helps resolve ethical and clinical concerns. Consideration of these factors does not necessarily facilitate learning. Clinical judgment uses other factors as well. MULTIPLE RESPONSE 1. Which of the following is a National Patient Safety Goal? (Select all that apply.) a. Accurately identify patients. b. Eliminate use of patient restraints. c. Reconcile medications across the continuum of care. d. Reduce risks of healthcare-acquired infection. ANS: A, C, D All except for eliminating use of restraints are current National Patient Safety Goals. Hospitals have policies regarding use of restraints and are attempting to reduce the use of restraints; however, this is not a National Patient Safety Goal. 2. Which of the following is (are) official journal(s) of the American Association of Critical-Care Nurses? (Select all that apply.) a. American Journal of Critical Care b. Critical Care Clinics of North America c. Critical Care Nurse d. Critical Care Nursing Quarterly ANS: A, C American Journal of Critical Care and Critical Care Nurse are two official AACN publications. Critical Care Clinics and Critical Care Nursing Quarterly are not AACN publications. 3. The first critical care units were: (Select all that apply.) a. burn units. b. coronary care units c. recovery rooms. d. neonatal intensive care units. ANS: B, C Recovery rooms and coronary care units were the first units designated to care for critically ill patients. Burn and neonatal intensive care units were established as specialty units evolved. 4. Which of the following nursing activities demonstrates implementation of the AACN Standards of Professional Performance? (Select all that apply.) a. Attending a meeting of the local chapter of the American Association of Critical-Care Nurses in which a continuing education program on sepsis is being taught b. Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient and family c. Participating on the unit’s nurse practice council d. Posting an article from Critical Care Nurse on management of venous thromboembolism for your colleagues to read e. Using evidence-based strategies to prevent ventilator-associated pneumonia ANS: A, B, C, D, E All answers are correct. Attending a program to learn about sepsis—Acquires and maintains current knowledge and competency in patient care. Collaborating with pastoral services—Collaborates with the healthcare team to provide care in a healing, humane, and caring environment.Posting information for others—Contributes to the professional development of peers and other healthcare providers. Nurse practice council—Provides leadership in the practice setting. Evidence-based practices—Uses clinical inquiry in practice. 5. Which scenarios contribute to effective handoff communication at change of shift? (Select all that apply.) a. The nephrology consultant physician is making rounds and asks you to update her on the patient’s status and assist in placing a central line for hemodialysis. b. The noise level is high because twice as many staff members are present and everyone is giving report in the nurse’s station. c. The unit has decided to use a standardized checklist/tool for change-of-shift reports and patient transfers. d. You and the oncoming nurse conduct a standardized report at the patient’s bedside and review key assessment findings. ANS: C, D A reporting tool and bedside report improve handoff communication by ensuring standardized communication and review of assessment findings. Conducting report at the bedside also reduces noise that commonly occurs at the nurse’s station during a change of shift. The nephrologist has created an interruption that can impede handoff with the next nurse. Likewise, noise in the nurse’s station can cause distractions that can impair concentration and listening. 6. Which strategy is important to addressing issues associated with the aging workforce? (Select all that apply.) a. Allowing nurses to work flexible shift durations b. Encouraging older nurses to transfer to an outpatient setting that is less stressful c. Hiring nurse technicians that are available to assist with patient care, such as turning the patient d. Remodeling patient care rooms to include devices to assist in patient lifting ANS: A, C, D Modifying the work environment to reduce physical demands is one strategy to assist the aging workforce. Examples include overhead lifts to prevent back injuries. Twelve-hour shifts can be quite demanding; therefore, allowing nurses flexibility in choosing shifts of shorter duration is a good option as well. Adequate staffing, including non-licensed assistive personnel, to help with nursing and non-nursing tasks is helpful. Encouraging experienced, knowledgeable critical care nurses to leave the critical care unit is not wise as the unit loses the expertise of this group. 7. Which of the following strategies will assist in creating a healthy work environment for the critical care nurse? (Select all that apply.) a. Celebrating improved outcomes from a nurse-driven protocol with a pizza party b. Implementing a medication safety program designed by pharmacists c. Modifying the staffing pattern to ensure a 1:1 nurse/patient ratio d. Offering quarterly joint nurse-physician workshops to discuss unit issues e. Using the Situation-Background-Assessment-Recommendation (SBAR) technique for handoff communication ANS: A, D, E Meaningful recognition, true collaboration, and skilled communication are elements of a healthy work environment. Implementing a medication safety program enhances patient safety, and if done without nursing input, could have negative outcomes. Staffing should be adjusted to meet patient needs and nurse competencies, not have predetermined ratios that are unrealistic and possibly not needed. Ch 2 1. Family members have a need for information. Which interventions best assist in meeting this need? a. Handing family members a pamphlet that explains all of the critical care equipment b. Providing a daily update of the patient’s progress and facilitating communication with the intensivist c. Telling them that you are not permitted to give them a status report but that they can be present at 4:00 PM for family rounds with the intensivist d. Writing down a list of all new medications and doses and giving the list to family members during visitation ANS: B The nurse can give a status report related to the patient’s condition and current treatment plan as well as ensure that the family has daily meeting time with the intensivist for an update on diagnoses, prognoses, and the like. Pamphlets are helpful; however, the nurse should also explain the equipment that is at this patient’s bedside and not assume that everyone can read and understand written material. Limiting the information to that provided by the physician is unnecessary and will not meet the family’s information needs. Most family members are concerned about the patient’s general condition and treatment plan. They do not want or need a detailed list of medications, doses, or other treatments. 2. The nurse is a member of a committee to design a critical care unit in a new building. Which design trend would best to facilitate family-centered care? a. Ensure that the patient’s room is large enough and has adequate space for a sleeper sofa and storage for family members’ personal belongings. b. Include a diagnostic suite in close proximity to the unit so that the patient does not have to travel far for testing. c. Incorporate a large waiting room on the top floor of the hospital with a scenic view and amenities such as coffee and tea. d. Provide access to a scenic garden for meditation. ANS: A New unit design trends to promote family-centered care include larger patient rooms that include a larger family space and comfortable furniture and storage to promote open visitation, including overnight stays in the patient’s room. Ready access to diagnostic testing, including portable equipment, is an important trend; however, the purpose for this is to prevent the need for transport, not to foster family-centered care. A waiting room in close proximity to the unit with amenities is a nice feature; however, it does not need to be large if adequate space is incorporated into the patient’s room. A scenic garden for medication may assist in reducing family members’ stress, but proximity to the patient is the greatest need. 3. The nurse is caring for a patient who sustained a head injury and is unresponsive to painful stimuli. Which intervention is most appropriate while bathing the patient? a. Ask a family member to help you bathe the patient, and discuss the family structure with the family member during the procedure. b. Because she is unconscious, complete care as quickly and quietly as possible. c. Tell the patient the day and time, and that you are bathing her. Reassure her that you are there. d. Turn the television on to the evening news so that you and the patient can be updated to current events. ANS: C Although unconscious, many patients can hear, understand, and respond to stimuli. Therefore, it is important to converse with the patient and reorient her to the environment. Some, but not all, family members may want to get involved in direct care; it is not known if this individual is a willing participant, and talking about who’s who in the family is not appropriate while providing direct care to the patient. Although she is unconscious, communication and simple conversations remain important interventions. Use of the television to provide sensory input that the patient regularly enjoys is a nursing intervention, but turning on the news for the sake of the nurse is not appropriate. 4. Sleep often is disrupted for critically ill patients. Which nursing intervention is most appropriate to promote sleep and rest? a. Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals. b. Encourage family members to talk with the patient whenever they are present in the room. c. Keep the television on to provide “white” noise and distraction. d. Leave the lights on in the room so that the patient is not frightened of his or her surroundings. ANS: A Planning care to promote periods of uninterrupted rest is important. Consulting with the pharmacist to adjust a medication schedule is an excellent example of this intervention. It is important for family members to communicate with the patient; however, rest periods must be scheduled. Family members can be present in the room while remaining quiet during these scheduled times. The television may be useful if it is part of the patient’s normal routine for sleep; however, it does not consistently provide “white noise” or distraction. Lights should be dimmed during scheduled rest periods and at night to facilitate sleep and rest. 5. Family assessment is essential in order to meet family needs. Which of the following must be assessed first to assist the nurse in providing family-centered care? a. Assessment of patient and family’s developmental stages and needs b. Description of the patient’s home environment c. Identification of immediate family, extended family, and decision makers d. Observation and assessment of how family members function with each other ANS: C Assessment of the family structure is the first step and is essential before specific interventions can be designed. It identifies immediate family, extended family, and decision makers in the family. Structural assessment also includes ethnicity and religion. The developmental assessment is done after the structural assessment and includes the developmental stages of the patient and family. Functional assessment is also important to assess how family members function with each other; however, it is not done first. Assessment of the home environment is important when identifying discharge planning needs. 6. Critical illness often results in family conflicts. Which scenario is most likely to result in the greatest conflict? a. A 21-year-old college student of divorced parents hospitalized with multiple trauma. She resides with her mother. The parents are amicable with each other and have similar values. The father blames the daughter’s boyfriend for causing the accident. b. A 36-year-old male admitted for a ruptured cerebral aneurysm. He has been living with his 34-year-old girlfriend for 8 years, and they have a 4-year-old daughter. He does not have written advance directives. His parents arrive from out-of-state and are asked to make decisions about his health care. He has not seen them in over a year. c. A 58-year-old male admitted for coronary artery bypass surgery. He has been living with his same-sex partner for 20 years in a committed relationship. He has designated his sister, a registered nurse, as his healthcare proxy in a written advance directive. d. A 78-year-old female admitted with gastrointestinal bleeding. Her hemoglobin is decreasing to a critical level. She is a Jehovah’s Witness and refuses the treatment of a blood transfusion. She is capable of making her own decisions and has a clearly written advance directive declining any transfusions. Her son is upset with her and tells her she is “committing suicide.” ANS: B Each of these situations may result in family conflict. The situation with the unmarried couple without written advance directives results in the distant parents being legally responsible for his healthcare decisions. Because of his long-standing commitment with his partner, and lack of recent contact with his parents, this scenario is likely to cause the most conflict. The parents may make decisions based on their wishes, as they may not be knowledgeable of the patient’s wishes. The supportive parents of the college student may create conflict with the boyfriend, but their ongoing friendship and shared values will assist in reducing conflict. The male admitted for bypass surgery, although in a same-sex relationship, has clearly identified who he wants to make healthcare decisions for him. The elderly female may have conflict with her son; however, she is capable of making her own decisions and has written advance directives to support her decisions. 7. Which nursing interventions would best support the family of a critically ill patient? a. Encourage family members to stay all night in case the patient needs them. b. Give a condition update each morning and whenever changes occur. c. Limit visitation from children into the critical care unit. d. Provide beverages and snacks in the waiting room. ANS: B The need for information is one of the highest identified by family members of critically ill patients. New room designs provide space for family members to spend the night if desired; however, if the patient is stable, family members should be encouraged to sleep at home to ensure that they are well rested and can support the patient. Restriction of children in the critical care unit is not supported by research evidence. Child visitation should be individualized based on the needs and wishes of the patient and family. Beverages and snacks are important but not as important as information. 8. Which intervention is appropriate to assist the patient to cope with admission to the critical care unit? a. Allowing unrestricted visiting by several family members at one time b. Explaining all procedures in easy-to-understand terms c. Providing back massage and mouth care d. Turning down the alarm volume on the cardiac monitor ANS: B Communication and explanations of procedures are priority interventions to help patients cope with admission. Comfort is an important intervention but not the priority. Noise control is an important intervention but not the priority. Open visitation is recommended; however, the number of family members may need to be limited to promote rest and sleep. 9. The constant noise of a ventilator, monitor alarms, and infusion pumps predisposes the patient to: a. anxiety. b. pain. c. powerlessness. d. sensory overload. ANS: D Constant noise is a source of sensory overload. Pain and lack of information contribute to anxiety. Noise does not cause physical pain. Lack of involvement in care causes powerlessness. DIF: Cognitive Level: Application REF: pp. 14-15 OBJ: Describe stressors in the critical care environment and strategies to reduce them. TOP: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 10. Which of the following statements about family assessment is false? a. Assessment of structure (who comprises the family) is the last step in assessment. b. Interaction among family members is assessed. c. It is important to assess communication among family members to understand roles. d. Ongoing assessment is important, because family functioning may change during the course of illness. ANS: A Assessment of structure should be done first so that the nurse can identify such things as who comprises the family and who assumes leadership and decision-making responsibilities. This assessment also assists in identifying which individuals are most important to the patient and how many people may be seeking information. Family member interaction must be assessed, so this answer is true. Family member communication must be assessed, so this answer is true. Ongoing assessment of family is necessary as functions may change, so this answer is true. 11. Which intervention about visitation in the critical care unit is true? a. The majority of critical care nurses implement restricted visiting hours to allow the patient to rest. b. Children should never be permitted to visit a critically ill family member. c. Visitation that is individualized to the needs of patients and family members is ideal. d. Visiting hours should always be unrestricted. ANS: C Visiting should be based on the needs of patients and their families. There may be times that visiting needs to be limited (e.g., to allow the patient to rest); however, it is important to individualize visitation. Sometimes it is appropriate for children to visit; research has not found child visitation to be harmful to either the patient or the child. Visiting should be adjusted to patient needs. 12. Elderly patients who require critical care treatment are at risk for increased mortality, functional decline, or decreased quality of life after hospitalization. Assuming each of these patients was discharged from the hospital, which of the following patients is at greatest risk for decreased functional status and quality of life? a. A 70-year-old who had coronary artery bypass surgery. He developed complications after surgery and had difficulty being weaned from mechanical ventilation. He required a tracheostomy and gastrostomy. He is being discharged to a long-term, acute care hospital. He is a widower. b. A 79-year-old admitted for exacerbation of heart failure. She manages her care independently but needed diuretic medications adjusted. She states that she is compliant with her medications but sometimes forgets to take them. She lives with her 82-year-old spouse. Both consider themselves to be independent and support each other. c. A 90-year-old admitted for a carotid endarterectomy. He lives in an assisted living facility (ALF) but is cognitively intact. He is the “social butterfly” at all of the events at the ALF. He is hospitalized for 4 days and discharged to the ALF. d. An 84-year-old who had stents placed to treat coronary artery occlusion. She has diabetes that has been managed, lives alone, and was driving prior to hospitalization. She was discharged home within 3 days of the procedure. ANS: A Although he is younger, the 70-year-old with the complicated critical care course, with limited social support, who is being discharged to a long-term acute care facility, is at greatest risk for decreased quality of life and functional decline. He will continue to need high-level nursing care and support for rehabilitation. The other cases are examples of individuals with shorter hospital stays, uncomplicated courses, and social support systems. 13. Patients often have recollections of the critical care experience. Which is likely the most common recollection from a patient who required endotracheal intubation and mechanical ventilation? a. Difficulty communicating b. Inability to get comfortable c. Pain d. Sleep disruption ANS: A Although the patient may recall all of these potential experiences, recollection of difficult communication is most likely secondary to the endotracheal tube placement. 14. Many critically ill patients experience anxiety. The nurse can reduce anxiety with which approach? a. Ask family members to limit their visitation to 2-hour periods in morning, afternoon, and evening. You know that this is the best approach to ensure uninterrupted rest time for the patient. Tell the patient, “Mr. J., your family is in the waiting room. They will be permitted to come in at 2:00 PM after you take a short nap.” b. Explain the unit routine. “Mr. J., assessments are done every 4 hours; patients are bathed on the night shift around 5:00 AM; family members are permitted to visit you after the physicians make their morning rounds. They can spend the day. Lights are out every night at 10:00 PM.” c. State, “Mr. J., it’s time to turn you. I am going to ask another nurse to come in and help me. We will turn you to your left side. During the turn, I’m going to inspect the skin on your back and rub some lotion on your back. This should help to make you feel better.” d. Suction Mr. J.’s endotracheal tube immediately when he starts to cough. Tell him, “Mr. J., your tube needs suctioned; you should feel better after I’m done.” ANS: C Anxiety is reduced when procedures are explained prior to completing them. In this example, the nurse clearly explains what will be done and what the patient can expect during turning. Limiting family members, especially if they are already present in the hospital, is not an approach that will reduce anxiety. Family members can be present in the room while allowing the patient to rest. It is important to orient the patient to the unit, but the explanation of a “unit routine” does not give the patient any control over things such as bathing, sleep times, and visitors. Suctioning is important, but only when indicated, which might not be with every coughing episode. Additionally, it is important to explain the procedure and tell the patient what to expect. 15. Which statement is a likely response from someone who has survived a stay in the critical care unit? a. “I don’t remember much about being in the ICU, but if I had to be treated there again, it would be okay. I’m glad I can see my grandchildren again.” b. “If I get that sick again, do not take me to the hospital. I would rather die than go through having a breathing tube put in again.” c. “My family is thrilled that I am home. I know I need some extra attention, but my children have rearranged their schedules to help me out.” d. “Since I have been transferred out of the ICU, I cannot get enough to eat. They didn’t let me eat in the ICU, so I’m making up for it now.” ANS: A Survivors of critical illness express a variety of concerns; however, most identify a willingness to undergo critical care treatment to prolong survival. Most survivors are not going to decline treatment for future hospitalizations (B). Although the patient’s family may be thrilled that he or she is home, challenges to family dynamics often occur, especially if family member’s schedules and routines are disrupted (C). Many patients have poor appetites after discharge from critical care, not ravenous ones (D). 16. The nurse is assigned to care for a patient who is a non-native English speaker. What is the best way to communicate with the patient and family to provide updates and explain procedures? a. Conduct a Google search on the computer to identify resources for the patient and family in their native language. Print these for their use. b. Contact the hospital’s interpreter service for someone to translate. c. Get in touch with one of the residents that you know is fluent in the native language and ask him if he can come up to the unit. d. Use the 8-year old child who is fluent in both English and the native language to translate for you. ANS: B The best approach when communicating with someone whose primary language is not English is to contact the interpreter services of the agency. These individuals are trained and knowledgeable. If the nurse conducted a search on the computer, she would not know if the information retrieved was valid nor would she know if the patient or family can read in their native language. Although one of the residents might be fluent in the language, you do not know his abilities to translate. In addition, his availability is likely to be limited. Although the child might be able to translate, the nurse cannot ensure that the child is translating healthcare concepts correctly. 17. Family assessment can be challenging and each nurse may obtain additional information regarding family structure and dynamics. What is the best way to share this information from shift to shift? a. Create an informal family information sheet that is kept on the bedside clipboard. That way, everyone can review it quickly when needed. b. Develop a standardized reporting form for family information that is incorporated into the patient’s medical record and updated as needed. c. Require that the charge nurse have a detailed list of information about each patient and family member. Thus, someone on the unit is always knowledgeable about potential issues. d. Try to remember to discuss family structure and dynamics as part of the change-of-shift report. ANS: B A standardized method for gathering data about family structure and function and recording it in an official document is the best approach. This strategy ensures that data are collected and kept in the medical record. Data are also easily retrievable by anyone who needs to know this information. Informal documentation is often kept to assist in follow-up and change-of-shift reporting; however, this strategy is not recommended, as data collected are likely to vary and not be part of a permanent record. Although the charge nurse often has some information regarding families, the primary responsibility for assessment and follow-up belongs to the bedside nurse. Family information should be shared at change of shift using a standardized format, not “try to remember to discuss… .” 18. The wife of a patient who is hospitalized in the critical care unit following resuscitation for a sudden cardiac arrest at work demands to meet with the nursing manager. She states, “I want you to reassign my husband to another nurse. His current nurse is not in the room enough to make sure he is okay.” The nurse recognizes that this response most likely is due to the wife’s: a. desire to pursue a lawsuit if the assignment is not changed. b. inability to participate in the husband’s care. c. lack of prior experience in a critical care setting. d. sense of loss of control of the situation. ANS: D Demanding behaviors often occur when the family member has a sense of loss of control or has had adverse outcomes in a previous hospitalization. Prevention of a lawsuit is not relevant to this scenario. No information is provided regarding whether the family member is participating in care or not. It is not known if she had a prior negative experience or not. 19. Open visitation policies are expected by many professional organizations. Which statement reflects adherence to current recommendations? a. Allow animals on the unit; however, these can only be “therapy” animals through the hospital’s pet therapy program. b. Allow family visitation throughout the day except at change of shift and during rounds. c. Determine, in collaboration with the patient and family, who can visit and when. Facilitate open visitation policies. d. Permit open visitation by adults 18 years of age and older; limit visits of children to 1 hour. ANS: C Open visitation is recommended by both the Society of Critical Care Medicine (SCCM) and the American Association of Critical-Care Nurses. SCCM suggests developing visitation schedules in collaboration with the patient and family. Animals do not need to be limited to therapy animals. Many patients benefit by the presence of their personal pets that are brought to the unit according to hospital policy. Although many units restrict visitation during report and rounds, the organizations encourage that such restrictions be loosened. Many institutions encourage family participation during report and rounds. Children should not be banned arbitrarily from the unit or have hours limited. 20. The VALUE mnemonic is a helpful strategy to enhance communication with family members of critically ill patients. Which of the following statements describes a VALUE strategy? a. View the family as guests on the unit. b. Acknowledge family emotions. c. Learn as much as you can about family structure and function. d. Use a trained interpreter if the family does not speak English. e. Evaluate each encounter with the family. ANS: B The VALUE mnemonic includes the following: V—Value what the family tells you. A—Acknowledge family emotions. L—Listen to the family members. U—Understand the patient as a person. E—Elicit (ask) questions of family members. DIF: Cognitive Level: Comprehension REF: pp. 20-21 | Box 2-3 OBJ: Describe common family needs and family-centered nursing interventions. TOP: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 21. Changing visitation policies can be challenging. The nurse manager recognizes the following as an effective strategy for promoting changes in practice: a. Ask the clinical nurse specialist to lead a journal club on open visitation after each nurse is tasked to read one research article about visitation. b. Discuss pros and cons of open visitation at the next staff meeting. c. Invite the nurses with the most experience to develop a revised policy. d. Task the unit-based nurse practice council to invite volunteers to serve on the council to revise the current policy toward more liberal visitation. ANS: D Changes in policy are most effective through willing champions as part of a unit-based, staff-led practice council. Discussion of evidence-based findings is important, but it is not logical to expect every nurse to read a research article and share findings. Discussion of pros and cons at a staff meeting is likely to be prolonged and based on opinion rather than evidence. Nurses with the most experience are not necessarily the ones to develop a new policy. They may be the least likely to change; therefore, it is important to solicit volunteers from all staff members, not just the experienced ones. MULTIPLE RESPONSE 1. Nursing strategies to help families cope with the stress of critical illness include: (Select all that apply.) a. asking the family to leave during the morning bath to promote the patient’s privacy. b. encouraging family members to make notes of questions they have for the physician during family rounds. c. if possible, providing continuity of nursing care. d. providing a daily update of the patient’s condition to the family spokesperson. ANS: B, C, D Encouraging families to formulate questions assists in family care. Continuity of nursing care with consistent staff members assists in reducing stress. Communication of patient condition update meets the need for information. Family members often want to assist with simple activities of patient care, so limiting participation is the exception to this list. 2. Family presence is encouraged during resuscitation and invasive procedures. The nurse knows that nurses are often reluctant to allow this to occur, yet families often perceive benefits. Which findings have been reported in the literature? (Select all that apply.) a. Families benefit by witnessing that everything possible was done. b. Families report reduced anxiety and fear about what is being done to the patient. c. Presence encourages family members to seek litigation for improper care. d. Presence reduces nurses’ involvement in explaining things to the family. ANS: A, B Families benefit from witnessing procedures and resuscitation. Being present helps family members to remove doubt about the condition, witness that everything was done, and decrease anxiety about what is occurring. Increased litigation has not been associated with family presence. Policies and procedures are needed to facilitate family presence. A facilitator is needed, and it may initially require more nursing involvement. It does not eliminate nurses’ responsibility for communicating with the family. 3. Noise in the critical care unit can have negative effects on the patient. Which of the following interventions assists in reducing noise levels in the critical care setting? (Select all that apply.) a. Ask the family to bring in the patient’s i-Pod or other device with favorite music. b. Invite the volunteer harpist to play on the unit on a regular basis. c. Remodel the unit to have two-patient rooms to facilitate nursing care. d. Remodel the unit to install acoustical ceiling tiles. e. Turn the volume of equipment alarms as low as they can be adjusted, and “off” if possible. ANS: A, B, D A personal device with favorite music and headphones can be helpful in reducing ambient unit noise. Music therapy programs, such as harpists, can provide soothing sedative music that is often comforting to both patients and family members. Acoustical tiles help to reduce noise in the critical care setting and should be included in remodeling plans as well as new unit construction. Multiple patients in a single room would increase noise levels and contribute to an increased risk of infection. Alarms on critical equipment must never be turned off. The volume should be loud enough that the alarm can be heard by the nurse if outside the room. The lowest setting may not be loud enough, depending on the unit layout and patient assignment. 4. It is important for critically ill patients to feel safe. Which nursing strategies help the patient to feel safe in the critical care setting? (Select all that apply.) a. Allow family members to remain at the bedside. b. Be sure to consult with the charge nurse before making any patient care decisions. c. Provide informal conversation by discussing your plans for after work. d. Respond promptly to call bells or other communication for assistance. ANS: A, D Patients feel safe when nurses exhibit technical competence, meet their needs, and provide reorientation. Family member presence may also contribute to feeling safe. Consulting with the charge nurse before making decisions may be interpreted as incompetence or insecurity. The nurse’s personal activities should never be discussed with patients. 5. The critical care environment is often stressful to a critically ill patient. Identify stressors that are common. (Select all that apply.) a. Alarms that sound from various devices b. Bright, fluorescent lighting c. Lack of day-night cues d. Sounds from the mechanical ventilator e. Visiting hours tailored to meet individual needs ANS: A, B, C, D Adjustment of visiting hours to meet needs of patients and families assists in reducing the stress of critical illness. All other responses are environmental stressors that increase anxiety, affect sleep, and the like. 6. A patient and his family are excited that he is transferring from the critical care unit to the intermediate care unit. However, they are also fearful of the change in environment and nursing staff. To reduce relocation stress, the nurse can: (Select all that apply.) a. ask the nurses on the intermediate care unit to give the family a tour of the new unit. b. contact the intensivist to see if the patient can stay one additional day in the critical care unit so that he and his family can adjust better to the idea of a transfer. c. ensure that the patient will be located near the nurse’s station in the new unit. d. invite the nurse who will be assuming the patient’s care to meet with the patient and family in the critical care unit prior to transfer. ANS: A, D Patients often have stress when they are moved from the safety of the critical care unit. Introducing the patient and his family to the nurse who will assume care and to the new environment are strategies to reduce relocation stress. Although the patient and his family may feel safer in a room near the nurse’s station, bed placement is determined by a variety of factors and cannot be guaranteed. Beds in the critical care unit are at a premium, and once the physician has determined that the patient no longer meets critical care admission requirements, it is essential that transfers be made once a bed on the intermediate care unit is available. 7. The critical care environment is stressful to the patient. Which interventions assist in reducing this stress? (Select all that apply.) a. Adjust lighting to promote normal sleep-wake cycles. b. Provide clocks, calendars, and personal photos in the patient’s room. c. Talk to the patient about other patients you are caring for on the unit. d. Tell the patient the day and time when you are providing routine nursing interventions. ANS: A, B, D Manipulation of the environment, such as adjusting lighting, is helpful in promoting sleep and rest; clocks, calendars, photos, and other personal items promote orientation and personalize the environment; telling the patient the day and time and other current events assists in maintaining the patient’s orientation. Conversations about other patients are private and should take place away from other patients Ch 3 1. Ideally, an advance directive should be developed by the: a. family, if the patient is in critical condition. b. patient as part of the hospital admission process. c. patient before hospitalization. d. patient’s healthcare surrogate. ANS: C Advance directives should be made and signed while a person is in good health and in a state of mind to make decisions about what should happen if he or she becomes incapacitated (e.g., during a critical illness). Families help to make decisions based on written advance directives, but families are not responsible for developing them for the patient. Developing advance directives during the admission process is not feasible, and the patient may not be capable of making an advance directive. The surrogate or proxy is one who has been already designated by a person to make healthcare decisions based on written advance directives. 2. A critically ill patient has a living will in his chart. His condition has deteriorated. His wife says she wants “everything done,” regardless of the patient’s wishes. Which ethical principle is the wife violating? a. Autonomy b. Beneficence c. Justice d. Nonmaleficence ANS: A Autonomy is respect for the individual and the ability of individuals to make decisions with regard to their own health and future. The wife is violating the patient’s autonomy in decision making. Beneficence consists of actions intended to benefit the patients or others. Justice is being fair. Nonmaleficence is the duty to prevent harm. 3. Which statement regarding ethical concepts is true? a. A living will is the same as a healthcare proxy. b. A signed donor card ensures that organ donation will occur in the event of brain death. c. A surrogate is a competent adult designated by a person to make healthcare decisions in the event the person is incapacitated. d. A persistent vegetative state is the same as brain death in most states. ANS: C A surrogate is a competent adult designated by a person to make healthcare decisions if that person becomes incapacitated. A living will is a witnessed document that states a person’s wishes regarding life-prolonging procedures, whereas a healthcare proxy is a person authorized by state statute to make healthcare decisions. In many states, consent by family members or healthcare proxy is required for organ donation even if an individual has a signed donor card. A persistent vegetative state is a permanent, irreversible unconscious condition that demonstrates an absence of voluntary action or cognitive behavior, or an inability to communicate or interact; brain death is cessation of brain function. 4. Which of the following statements about resuscitation is true? a. Family members should never be present during resuscitation. b. It is not necessary for a physician to write “do not resuscitate” orders in the chart if a patient has a healthcare surrogate. c. “Slow codes” are ethical and should be considered in futile situations if advanced directives are not available. d. Withholding “extraordinary” resuscitation is legal and ethical if specified in advance directives and physician orders. ANS: D Withholding resuscitation and other care is legal and ethical if based on the patient’s wishes. Formal orders should be written that specify what is to be done if a patient suffers a cardiopulmonary arrest. Family presence during resuscitation and invasive procedures should be encouraged. A written order for “do not resuscitate” must be documented in the medical record. The decision to write the order is made in collaboration with the healthcare surrogate. “Slow codes” sometimes occur in the clinical setting while attempts are made to contact the healthcare surrogate or proxy; however, they are neither legal nor ethical. Specific written orders determine what is to be done for resuscitation efforts. 5. The nurse is caring for an elderly patient who is in cardiogenic shock. The patient has failed to respond to medical treatment. The intensivist in charge of the patient conducts a conference to explain that they have exhausted treatment options and suggest that the patient be made a “do not resuscitate” status. This scenario illustrates the concept of: a. brain death. b. futility. c. incompetence. d. life-prolonging procedures. ANS: B This is the definition of futility. Brain death is cessation of brain function and is not described in this scenario. Incompetence (in this chapter) is when a patient is unable to make decisions regarding healthcare treatment. A life-prolonging procedure is one that sustains, restores, or supplants a spontaneous vital function. 6. The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle crash. The patient’s Glasgow Coma Score is 3 and intermittently withdraws when painful stimuli are introduced. The patient is ventilator dependent and occasionally takes a spontaneous breath. The physician explains to the family that the patient has severe neurological impairment and he does not expect the patient to recover consciousness. The nurse recognizes that this patient is: a. an organ donor. b. brain dead. c. in a persistent vegetative state. d. terminally ill. ANS: C A persistent vegetative state is a permanent, irreversible unconscious condition that demonstrates an absence of voluntary action or cognitive behavior, or an inability to communicate or interact purposefully with the environment. She is not brain dead, as occasionally she reacts to painful stimuli and takes a spontaneous breath; therefore, she cannot be an organ donor at this time. Treatment of her condition may be considered futile; however, she would not be defined as terminally ill. 7. A nurse caring for a patient with neurological impairment often must use painful stimuli to elicit a patient’s response. The nurse uses subtle measures of painful stimuli, such as nailbed pressure. She neither slaps the patient nor pinches the nipple to elicit a response to pain. In this scenario, the nurse is exemplifying the ethical principle of: a. beneficence. b. fidelity. c. nonmaleficence. d. veracity. ANS: C Nonmaleficence is not to intentionally harm others. Beneficence demonstrates actions intended to benefit the patients or others. Fidelity is the moral duty to be faithful to the commitments that one makes to others. Veracity is the obligation to tell the truth. 8. Which of the following organizations requires a mechanism for addressing ethical issues? a. American Association of Critical-Care Nurses b. American Hospital Association c. Society of Critical Care Medicine d. The Joint Commission ANS: D The Joint Commission requires that a formal mechanism be in place to address patients’ ethical concerns. The other organizations do not address formal ethics committees. 9. The nurse is caring for a patient who is not responding to medical treatment. The intensivist holds a conference with the family, and a decision is made to withdraw life support. The nurse’s religious beliefs are not in agreement with withdrawal. However, she assists with the process to avoid confronting the charge nurse. Afterward she feels guilty and believes she “killed the patient.” This scenario is likely to cause: a. abandonment. b. family stress. c. moral distress. d. negligence. ANS: C Moral distress occurs when the nurse acts in a manner contrary to personal or professional values. Abandonment is defined as the unilateral severance of a professional relationship while a patient is still in need of health care. Family stress would not be impacted in this situation if the nurse responded appropriately during the procedure. Negligence is failure to act according to the standard of care. 10. The nurse is caring for a patient who has been declared brain dead. The patient is considered a potential organ donor. In order to proceed with donation, the nurse understands that: a. a signed donor card mandates that organs be retrieved in the event of brain death. b. after brain death has been determined, perfusion and oxygenation of organs is maintained until organs can be removed in the operating room. c. the healthcare proxy does not need to give consent for the retrieval of organs. d. once a patient has been established as brain dead, life support is withdrawn and organs are retrieved. ANS: B After brain death has been determined, the organs must be perfused to maintain viability. Therefore, the patient remains on life support even though he or she is legally dead. A signed donor card indicates the individual’s wishes; however, most organ procurement agencies require family consent even if a donor card has been signed. In most states, the healthcare surrogate or proxy is required to give consent for organ donation. After brain death has been determined, perfusion and oxygenation of organs are maintained until organs can be removed in the operating room. 11. The nurse is caring for a patient who is declared brain dead and is an organ donor. The following events occur: 1300 Diagnostic tests for brain death are completed. 1330 Intensivist reviews diagnostic test results and writes in the progress note that the patient is brain dead. 1400 Patient is taken to the operating room for organ retrieval. 1800 All organs have been retrieved for donation. The ventilator is discontinued. 1810 Cardiac monitor shows flatline. What is the official time of death recorded in the medical record? a. 1300 b. 1330 c. 1400 d. 1800 e. 1810 ANS: B The time of death is when brain death is confirmed and documented in the chart, even though the patient’s heart is still beating. Organs are retrieved after brain death has been documented. 12. The nurse is caring for a critically ill patient on mechanical ventilation. The physician identifies the need for a bronchoscopy, which requires informed consent. If the physician were to obtain consent from the patient, the patient must be able to: a. be weaned from mechanical ventilation. b. have knowledge and competence to make the decision. c. nod his head that it is okay to proceed. d. read and write in English. ANS: B Informed consent requires that a person know what is to be done and have the competence to make an informed decision. Most critically ill patients do not have this capacity; however, an assessment should be made to determine the patient’s capacity. Some patients on mechanical ventilation are able to give written consent. Reading and writing in English are not requirements for informed consent. 13. The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows ventricular tachycardia. The patient does not have a “do not resuscitate” order written on the chart. What is the appropriate nursing action? a. Contact the attending physician immediately to determine if CPR should be initiated. b. Contact the family immediately to determine if they want CPR to be started. c. Give emergency medications but withhold intubation. d. Initiate CPR and call a code. ANS: D Because no orders have been written, it is imperative that a code be called. In this example, decisions regarding resuscitation status should be determined as soon as possible before a code event. The physician and family should be contacted immediately to determine treatment options, but CPR is not withheld. It is not appropriate to conduct a “partial” code by giving medications only. 14. When addressing an ethical dilemma, contextual, physiological, and personal factors of the situation must be considered. Which of the following is an example of a personal factor? a. The hospital has a policy that everyone must have an advanced directive on the chart. b. The patient has lost 20 pounds in the past month and is fatigued all of time. c. The patient has told you what quality of life means and his or her wishes. d. The physician considers care to be futile in a given situation. ANS: C Personal factors include competence, stated wishes, goals and hopes, definition of quality of life, and family relationships. Hospital policy is a contextual factor. Weight loss and fatigue are physiological factors. The physician’s belief is a contextual factor. 15. A specific request made by a competent person that directs medical care related to life-prolonging procedures if the patient loses capacity to make decisions is called a: a. do not resuscitate order. b. healthcare proxy. c. informed consent. d. living will. ANS: D A living will is a formal advance directive that directs medical care related to life-prolonging procedures when a person does not have the capacity to make decisions regarding health care and treatment. A do not resuscitate order is a legal medical order prohibiting resuscitation measures in the event of clinical death. A healthcare proxy is an individual designated by the person to make decisions if incapacitated. Informed consent involves decisions regarding treatments and procedures following explanation of risks and benefits. 16. The American Nurses Credential Center Magnet Recognition Program supports many actions to ensure that nurses are engaged and empowered to participate in ethical decision making. Which of the following would assist nurses in being involved in research studies? a. Education on protection of human subjects b. Participation of staff nurses on ethics committees c. Written descriptions of how nurses participate in ethics programs d. Written policies and procedures related to response to ethical issues ANS: A Completion of education related to human subject protection assists nurses in research. Ethics committees, ethics programs, and policies address ethics issues rather than prepare nurses for research. 17. The critical care nurse wants a better understanding of when to initiate an ethics consult. After attending an educational program, she understands that the following situation would require an ethics consultation: a. Conflict has occurred between the physician and family regarding treatment decisions. A family conference is held, and the family and physician agree to a treatment plan that includes aggressive treatment for 24 hours followed by re-evaluation. b. Family members disagree as to a patient’s course of treatment. The patient has designated a healthcare proxy and has a written advance directive. c. Patient postoperative coronary artery bypass surgery who sustained a cardiopulmonary arrest in the operating room. He was successfully resuscitated, but now is not responding to treatment. He has a written advance directive and his wife is present. d. Patient with multiple trauma and is not responding to treatment. No family members are known, and care is considered futile. ANS: D In the case of a seriously ill patient who is incapacitated and does not have a surrogate, an ethics consultation is warranted. The conflict has been resolved in the case of the family and physician agreeing on a course of treatment for 24 hours followed by re-evaluation. Although family members disagree, if a patient has a written advance directive and a designated healthcare proxy, an ethics consultation is not warranted; the patient’s wishes are clearly known. The cardiac surgery patient has a written directive to guide his treatment. 18. The nurse is aware that a shortage of organs exists. She knows that which of the following statements is true? a. Anyone who is comfortable approaching the family should discuss the option of organ donation. b. Brain death determination is required before organs can be retrieved for transplant. c. Donation of selected organs after cardiac death is ethically acceptable. d. Family members should consider withdrawing life support so that the patient can become an organ donor. ANS: C Donation of selected organs after cardiac death is ethically and legally appropriate. Specific policies and procedures for donation after cardiac death facilitate this procedure. Only designated requestors who are knowledgeable and trained in organ donation should approach the family to discuss donation. Organs can be retrieved not only after brain death but also after cardiac death. The decision to withdraw life support should be made separately from the decision to donate organs. MULTIPLE RESPONSE 1. Warning signs that can assist the critical care nurse in recognizing that an ethical dilemma may exist include which of the following? (Select all that apply.) a. Family members are confused about what is happening to the patient. b. Family members are in conflict as to the best treatment options. They disagree with each other and cannot come to consensus. c. The family asks that the patient not be told of treatment plans. d. The patient’s condition has changed dramatically for the worse and is not responding to conventional treatment. e. The physician is considering trying a medication that is not approved to treat the patient’s condition. ANS: A, B, C, D, E All of these are potential signs of an ethical dilemma. 2. The nurse is caring for a patient whose condition has deteriorated and who is not responding to standard treatment. The physician calls for an ethical consultation with the family to discuss potential withdrawal versus aggressive treatment. The nurse understands that applying a model for ethical decision making involves which of the following? (Select all that apply.) a. Burden versus benefit b. Family’s wishes c. Patient’s wishes d. Potential outcomes of treatment options ANS: A, C, D According to the ethical decision-making process, decisions should be made in light of the patient’s wishes (autonomy), burden versus benefit (beneficence), other relevant principles, and potential outcomes of various options. The patient’s wishes may differ from those of the family. 3. The nurse understands that many strategies are available to address ethical issues that may occur; these strategies include which of the following? (Select all that apply.) a. Change-of-shift report updates b. Ethics consultation services c. Formal multiprofessional ethics committees d. Pastoral care services ANS: B, C Formal mechanisms such as multiprofessional ethics committees or referral services are strategies to address ethical issues. Nurse-to-nurse communication can help share information from shift to shift, but it is not the best way to address ethical issues. Pastoral care representatives may serve on an ethics committee; however, their primary role is to support the spiritual needs of the patient and family. 4. The nurse is caring for a patient with severe neurological impairment following a massive stroke. The physician has ordered tests to determine brain death. The nurse understands that criteria for brain death include: (Select all that apply.) a. absence of cerebral blood flow. b. absence of brainstem reflexes on neurological examination. c. Cheyne-Stokes respirations. d. flat electroencephalogram. ANS: A, B, D Criteria for brain death include absence of cerebral blood flow, absence of brainstem reflexes, and flat electroencephalograph. The presence of Cheyne-Stokes respirations would indicate some brain function. 5. The nurse is caring for 80-year-old patient who has been treated for gastrointestinal bleeding. The family has agreed to withhold or withdraw additional treatment. The patient has a written advance directive specifying requests. The directive notes that the patient wants food and fluid to be continued. The nurse anticipates that several orders may be written to comply with this request, including which of the following? (Select all that apply.) a. “Do not resuscitate.” b. Change antibiotic to a less expensive medication. c. Discontinue tube feeding. d. Stop any further blood transfusions. ANS: A, D All orders except antibiotic adjustment may be considered withdrawal or withholding of life support and should be written only after informed consent from the healthcare surrogate or family has been obtained. Because the patient has expressed a request to not have food or fluids withdrawn, it would not be appropriate for the physician to write an order to discontinue the tube feeding. Ch 4 1. A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam (Ativan) 1 to 2 mg IV as needed (prn). The patient has received no lorazepam (Ativan) during this course of illness. What is the most appropriate nursing intervention to control agitation? a. Administer fentanyl (Duragesic) 25 mg IV bolus. b. Administer lorazepam (Ativan) 1 mg IV now. c. Increase the rate of the morphine infusion by 50%. d. Request an order for a paralytic agent. ANS: B Lorazepam (Ativan) 1 mg IV is an appropriate loading dose for a patient who is benzodiazepine naïve and experiencing agitation during withdrawal of life support. Fentanyl treats pain and morphine controls pain. Paralytic agents are not warranted. 2. A 75-year-old patient, who suffered a massive stroke 3 weeks ago, has been unresponsive and has required ventilatory support since the time of the stroke. The physician has approached the spouse regarding placement of a permanent feeding tube. The spouse states that the patient never wanted to be kept alive by tubes and personally didn’t want what was being done. After holding a family conference with the spouse, the medical team concurs and the feeding tube is not placed. This situation is an example of: a. euthanasia. b. palliative care. c. withdrawal of life support. d. withholding of life support. ANS: D Because the tube feeding had not been placed in the care of this patient, this scenario is an example of withholding of life support. Withholding of life support does not constitute euthanasia. Withdrawal of life support involves discontinuation of previously established therapies in a terminally ill patient. 3. What were the findings of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT)? a. Clear communication is typical in the relationships between most patients and healthcare providers. b. Critical care units often meet the needs of dying patients and their families. c. Disparities exist between patients’ care preferences and actual care provided. d. Pain and suffering of patients at end of life is well controlled in the hospital. ANS: C Disparities and lack of communication are common in the relationships between patients and healthcare providers. Critical care units are often poorly equipped to meet the needs of dying patients. The SUPPORT study demonstrated that pain and suffering is widespread in hospitals. 4. A statement that provides a legally recognized description of an individual’s desires regarding care at the end of life is a (an): a. advance directive. b. guardianship ad litem. c. healthcare proxy. d. power of attorney. ANS: A Legally recognized documents that provide guidance on an individual’s end-of-life choices are advance directives. Advance directives include living wills, durable power of attorney for health care, and healthcare surrogate designations. A guardianship ad litem is a parent who files legal action on the behalf of a child. A healthcare proxy is an individual who is legally designated through statute to make decisions for an incapacitated person. A power of attorney is an individual who is, through filing of legal papers, authorized to act on the behalf of an incapacitated person in legal matters. 5. A 65-year-old patient with a history of metastatic lung carcinoma has been unresponsive to chemotherapy. The medical team has determined that there are no additional treatments available that will prolong life or improve the quality of life in any meaningful way. Despite the poor prognosis, the patient continues to receive chemotherapy and full nutrition support. This is an example of what end-of-life concept? a. Medical futility b. Palliative care c. Terminal weaning d. Withdrawal of treatment ANS: A Medical futility is a situation in which therapy or interventions will not provide a foreseeable possibility of improvement in the patient’s health status. Palliative care focuses on symptom relief and is not limited to the dying. Terminal weaning refers to withdrawal of artificial ventilation interventions. Withdrawal of treatment refers to removal of established therapies in a terminally ill patient. 6. Designated healthcare surrogates should base healthcare decisions on: a. personal beliefs and values. b. recommendations of family members and friends. c. recommendations of the physician and healthcare team. d. wishes previously expressed by the patient. ANS: D Healthcare surrogates attempt to have decisions match the wishes of the patient. Although suggestions of family and friends may provide insight into patient desires, actual decisions should be based upon known patient wishes. The physician and healthcare team may provide recommendations, but decisions should be based upon the patient’s wishes. 7. Which statement made by a staff nurse identifying guidelines for palliative care would need corrected? a. Basic nursing care is a critical element in palliative care management. b. Common conditions that require palliative management are nausea, agitation, and sleep disturbance. c. Palliative care practices are reserved for the dying client. d. Palliative care practices relieve symptoms that negatively affect the quality of life of a patient. ANS: C The purpose of palliative care is to relieve negative symptoms that affect the quality of life of a patient. Palliative care is an integral part of every injured or ill patient’s care. Basic nursing care, including repositioning, skin care, and provision of a peaceful environment, promote comfort. These conditions all commonly require palliative care techniques. 8. Which statement is true regarding the impact of culture on end-of-life decision making? a. African-Americans prefer more conservative, less invasive care options during the end of life. b. Caucasians prefer aggressive and more invasive care options during the end of life. c. Culture and religious beliefs may affect end-of-life decision making. d. Perspectives regarding end-of-life care are similar between and within religious groups. ANS: C Religious doctrines and cultural beliefs have profound impact on end-of-life decisions. African-Americans prefer more aggressive and invasive end-of-life care options. Caucasians prefer less aggressive care options at the end of life. Perspectives on end-of-life care vary within and between religious groups. 9. The most critical element of effective early end-of-life decision making is: a. control of distressing symptoms such as nausea, anxiety, and pain. b. effective communication between the patient, family, and healthcare team throughout the course of the illness. c. organizational support of palliative care principles. d. relocation the dying patient from the critical care unit to a lower level of care. ANS: B The failure of clinicians, family members, and patients to openly discuss prognoses, end-of-life wishes, and preferences contributes to care conflicts such as in the Schiavo case. Early discussion of end-of-life wishes is required to promote positive outcomes for the patient and family, and actually should predate illness. Even though symptom control is a significant dimension of palliative care, it is not involved in initial end-of-life decision making. Adequate staffing and facility policies that support the dying patient are critical but should not impact family decision making. The patient should be cared for in an environment that best supports the needs of the patient and family. Even though organizational support of palliative principles is important, it should not drive individual decision making. 10. A patient with end-stage heart failure is experiencing considerable dyspnea. Appropriate pharmacological management of this symptom includes: a. administration of 6 mg of midazolam (Versed) and initiation of a continuous midazolam infusion. b. administration of morphine, 5 mg IV bolus, and initiation of a continuous morphine infusion. c. hourly increases of the midazolam (Versed) infusion by 100% dose increments. d. hourly increases of the morphine infusion by 100% dose increments. ANS: B Morphine is an excellent agent to control the symptom of dyspnea. A 5-mg IV bolus and initiation of a morphine drip is an appropriate initial intervention to control dyspnea. Initial dosing of midazolam should be 2 to 4 mg, and more is indicated for anxiety. The morphine dose should be titrated incrementally by 50% dose increases. Midazolam is indicated for management of dyspnea and is titrated incrementally by 50% dose increases. 11. Which statement is consistent with societal views of dying in the United States? a. Dying is viewed as a failure on the part of the system and providers. b. Most Americans would prefer to die in a hospital to spare loved ones the burden of care. c. People die of indistinct, complex illness for which a cure is always possible. d. The purpose of the healthcare system is to prevent disease and treat symptoms. ANS: A Death is viewed as a failure by society and healthcare providers that results in aggressive management of disease, even in unfavorable situations. Research has indicated that most Americans would prefer to die at home. There is a commonly held belief that people die of distinct diseases, implying that a cure is possible. There is a commonly held belief that the healthcare system exists to treat illness, disease, and injury and to “save” lives. 12. Which nursing intervention would need to be corrected on a care plan for a patient in order to be consistent with the principles of effective end-of-life care? a. Control of distressing symptoms such as dyspnea, nausea, and pain through use of pharmacological and nonpharmacological interventions b. Limitation of visitation to reduce the emotional distress experienced by family members c. Patient and family education on anticipated patient responses to withdrawal of therapy d. Provision of spiritual care resources as desired by the patient and family ANS: B Active involvement of family is a critical dimension of end-of-life care. Family members should have access to the patient and inclusion in care to the degree they desire. Limitation of visitors is not consistent with effective end-of-life care practices. Control of distressing symptoms is a dimension of end-of-life care. Family education and anticipatory guidance are critical elements of end-of-life care. Meeting the emotional and psychological needs of the patient and family through provision of spiritual resources and bereavement care is a critical element of end-of-life care. 13. In which of the following situations would a healthcare surrogate or proxy assume the end-of-life decision-making role for a patient? a. When a dying patient requires extensive heavy sedation, such as benzodiazepines and narcotics, to control distressing symptoms b. When a dying patient who is competent requests to withdraw treatment against the wishes of the family c. When a dying patient who is competent requests to continue treatment against the recommendations of the healthcare team d. When a dying patient who is competent is receiving prn treatment for pain and anxiety ANS: A A patient who requires heavy sedation, such as IV infusions of pain medications or anxiolytic medications, would not be competent to make healthcare decisions. A healthcare proxy or surrogate would be required in this situation. A patient who is deemed competent by the medical team may be responsible for healthcare decisions even if these are not consistent with family beliefs. A surrogate would not assume decision-making responsibilities in this situation. A healthcare team member who cannot support decisions would be responsible for finding an alternative care provider who could support the patient’s wishes. 14. Which statement is true regarding the effects of caring for dying patients on nurses? a. Attendance at funerals is inappropriate and will only create additional stress in nurses who are already at risk for burnout. b. Caring for dying patients is an expected part of nursing and will not affect the emotional health of the nurse if he or she maintains a professional approach with each patient and family. c. Most nurses who work with dying patients are able to balance care needs of patients with personal emotional needs. d. Provision of aggressive care to patients for whom they believe it is futile may result in personal ethical conflicts and burnout for nurses. ANS: D Burnout may occur when nurses must provide aggressive care to patients for whom they believe it is futile or when care choices made by patients and/or surrogates differ from those of clinicians. Attendance at funerals may relieve emotional strain in some situations. Meeting the emotional needs of patients and families often requires that the nurse invest emotionally while providing care. Maintaining a professional, healthy distance and being human when working with the dying is a difficult task that requires a great deal of balancing. 15. The family is considering withdrawing life-sustaining measures from the patient. The nurse knows that ethical principles for withholding or withdrawing life-sustaining treatments include which of the following? a. Any treatment may be withdrawn and withheld, including nutrition, antibiotics, and blood products. b. Doses of analgesic and anxiolytic medications must be adjusted carefully and should not exceed usual recommended limits. c. Life-sustaining treatments may be withdrawn while a patient is receiving paralytic agents. d. The goal of withdrawal and withholding of treatments is to hasten death and thus relieve suffering. ANS: A