A patient with a new pulmonary embolism (PE) is anxious.
What nursing actions are most appropriate? Select all that apply.
Acknowledge the frightening nature of the illness.
Give simple explanations of what is happening.
Request a prescription for antianxiety medications.
Stay with the patient and speak in a quiet, calm voice.
Correct Answer : A,B,D
Choice A rationale
Acknowledging the frightening nature of the illness is a crucial therapeutic communication technique. By validating the patient's feelings of fear and anxiety, the nurse establishes trust and rapport. This approach shows empathy and helps the patient feel understood, which can reduce psychological distress. It also provides a foundation for the patient to be more receptive to subsequent nursing interventions and education.
Choice B rationale
Providing simple, clear explanations of what is happening helps to demystify the situation and reduce the patient's anxiety. When a person is anxious, their cognitive processing can be impaired, making it difficult to comprehend complex information. Short, concise explanations about the cause of their symptoms and the purpose of interventions can help the patient feel more in control and less overwhelmed, thereby alleviating some of their fear.
Choice C rationale
Requesting a prescription for antianxiety medications is not the most appropriate immediate action. While medications may eventually be necessary, the initial nursing actions should focus on non-pharmacological interventions. These include therapeutic communication and supportive presence. Pharmacological interventions are typically reserved for situations where non-pharmacological methods are insufficient or the anxiety is severe enough to cause physiological instability.
Choice D rationale
Staying with the patient and speaking in a quiet, calm voice is a primary nursing action for an anxious patient. A calm, reassuring presence can help to de-escalate the patient's anxiety by providing a sense of security and support. The nurse's calm demeanor can also model appropriate emotional regulation for the patient, which can help to reduce their physiological and psychological distress. This action is simple, immediate, and highly effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Flail chest is the paradoxical movement of a section of the chest wall, caused by multiple rib fractures in two or more places. It is characterized by paradoxical chest wall motion, where the injured segment moves in during inspiration and out during expiration. While it is a severe chest injury, it does not typically involve a large accumulation of blood in the pleural space, which is the defining characteristic mentioned in the patient's presentation.
Choice B rationale
A tension pneumothorax is a life-threatening condition where air enters the pleural space but cannot exit, causing a rapid increase in intrathoracic pressure. This leads to tracheal deviation, hypotension, and profound respiratory distress. While it can cause a collapsed lung and dyspnea, the defining characteristic is air trapping, not blood accumulation in the pleural space, making this diagnosis inconsistent with the patient's specific presentation of hemothorax.
Choice C rationale
A simple pneumothorax is the presence of air in the pleural space, causing the lung to collapse, but without the one-way valve effect seen in a tension pneumothorax. It presents with dyspnea and asymmetrical chest expansion. While it causes a collapsed lung, the defining feature of this patient's case is the presence of a blood accumulation in the pleural space, which is not a hallmark of a simple pneumothorax.
Choice D rationale
A hemothorax is a medical condition characterized by the accumulation of blood in the pleural cavity, which is the space between the lungs and the chest wall. The presence of a collapsed lung, blood accumulation in the pleural space, dyspnea, and asymmetrical chest expansion directly corresponds to the classic presentation of a hemothorax. This diagnosis accurately and completely accounts for all the symptoms described in the patient's clinical scenario. .
Correct Answer is C
Explanation
Choice A rationale
Iron is a crucial component of hemoglobin and is essential for erythropoiesis. However, a significant burn injury primarily causes massive fluid shifts and plasma loss from the intravascular space into the interstitial spaces, leading to hypovolemia and hemoconcentration. Iron supplementation would not address the immediate, life-threatening fluid and protein depletion that characterizes the initial phase of a major burn.
Choice B rationale
PRBCs, or packed red blood cells, are used to restore oxygen-carrying capacity in the event of significant blood loss or anemia. While a burn patient may eventually become anemic, the immediate and most critical need following a major burn is the replacement of lost plasma volume and proteins, which is not effectively addressed by PRBCs alone.
Choice C rationale
A severe burn causes a substantial loss of plasma proteins, including albumin, globulins, and clotting factors, from the circulation due to increased capillary permeability. Fresh frozen plasma (FFP) is rich in these proteins and clotting factors, making it the most appropriate choice to restore intravascular volume, oncotic pressure, and hemostasis, thereby combating hypovolemic shock.
Choice D rationale
Albumin is a major plasma protein and is effective for increasing oncotic pressure and drawing fluid back into the vasculature. However, fresh frozen plasma (FFP) is a more comprehensive choice as it contains albumin along with other essential plasma proteins, coagulation factors, and immunoglobulins, which are all depleted following a severe burn injury
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