NUR 419 Quiz with Questions and Answers

NUR 419 Quiz with Questions and Answers A client in a critical care unit has increased stress from the constant noise and light levels. What nursing intervention best attenuates these sources of stress? A. Need for constant observation and evaluation B. Use of tile floors for ease in cleaning C. Frequent nursing group rounds for all clients D. Dimming lights during the night ANSWER D -Although constant observation and evaluation of clients is necessary in critical care, actions such as dimming lights when possible during hours of sleep, reducing unnecessary noise at night, and providing for the client's privacy can reduce some stress. The nurse is caring for a client who is orally intubated and on a mechanical ventilator. The nurse believes that the client is experiencing excess anxiety. For this client, what behavior best indicates anxiety? A. Restlessness B. Glasgow Coma Scale score of 3 C. Increased respiratory rate D. Verbalization ANSWER A -According to many critical care nurses, the top five physiologic and behavioral indicators of anxiety are agitated behavior, increased blood pressure, increased heart rate, verbalization of anxiety, and restlessness. For this client, verbalization is not possible due to oral intubation. Increased respiratory rate is not one of the most common behaviors. A Glasgow Coma Scale score of 3 is deep coma.