The emergency department team is performing cardiopulmonary resuscitation on a patient when the patient’s spouse arrives. What is the first action the nurse should take?
Ask the spouse if they wish to be present during the resuscitation.
Request that the patient’s spouse sit in the waiting room.
Refer the patient’s spouse to the hospital’s crisis team.
Suggest that the spouse begin to pray for the patient.
The Correct Answer is A
Choice A rationale:
It is crucial to prioritize the patient's spouse's emotional needs and preferences during this highly stressful and sensitive situation. Offering the choice to be present during resuscitation demonstrates respect for their autonomy, promotes family- centered care, and facilitates coping mechanisms.
Key considerations supporting this approach:
Respect for Autonomy:
Patients and their loved ones have the right to make informed decisions about their care, including being present during resuscitation efforts.
Respecting this right fosters trust, empowers the spouse, and aligns with ethical principles of patient autonomy. Family-Centered Care:
Family-centered care recognizes the importance of family members in the patient's care and decision-making.
Inviting the spouse to be present demonstrates a commitment to including them in the care process and supporting their emotional needs.
Facilitating Coping Mechanisms:
Witnessing resuscitation efforts can be distressing, but it can also provide closure, acceptance, and the opportunity to say goodbye.
Some individuals find comfort in being present and actively involved, even in difficult circumstances. The nurse can provide emotional support and guidance throughout the process.
Potential Benefits of Presence:
Studies have shown that family presence during resuscitation can have positive outcomes, such as decreased anxiety and post- traumatic stress disorder (PTSD) symptoms in family members.
It may also contribute to greater satisfaction with care and a sense of peace for those who choose to be present.
Rationales for other choices:
Choice B: Requesting that the spouse sit in the waiting room may isolate them and increase their anxiety. It deprives them of the opportunity to be involved in decision-making and potentially delays their grieving process.
Choice C: While the hospital's crisis team can provide valuable support, immediate referral may not align with the spouse's immediate needs or preferences. It's essential to first assess their emotional state and offer the choice of being present.
Choice D: Suggesting prayer may be appropriate for some individuals, but it should not be the first or only option presented. It's important to respect the spouse's spiritual beliefs and offer a range of support options.
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Correct Answer is C
Explanation
Choice A rationale:
While it's true that dehydration can lead to incontinence, simply stating this fact to the patient doesn't directly address the issue of dehydration. It doesn't provide actionable steps to correct the dehydration.
Incontinence can be a result of dehydration, but addressing the dehydration is the primary concern to prevent further complications.
Providing information about incontinence might be helpful in other contexts, but it's not the most effective advice to address mild dehydration in this specific scenario.
Choice B rationale:
Diuretics promote fluid loss through urination, which can worsen dehydration.
Advising the patient to take a diuretic in the morning would be counterproductive in this case. The goal is to increase fluid intake, not further deplete fluid levels.
It's important to consider the patient's medications and potential interactions before suggesting any changes to their medication regimen.
Choice C rationale:
Regular fluid intake is essential for maintaining hydration and replenishing lost fluids.
This advice directly addresses the issue of dehydration by encouraging the patient to consume fluids consistently. Drinking fluids every 1 to 2 hours can help restore fluid balance and prevent further complications.
It's a simple, actionable, and effective measure to address mild dehydration.
Choice D rationale:
While reducing sodium intake can be beneficial for some individuals with hypertension or other conditions, it's not the most relevant advice for addressing mild dehydration.
Sodium restriction might be appropriate in certain cases, but it doesn't directly address the immediate need to increase fluid intake.
The primary focus in this situation should be on replenishing fluids, not restricting sodium.
Correct Answer is A
Explanation
Choice A rationale:
Addresses the family's fear directly: By demonstrating how to avoid spreading the disease, the nurse directly addresses the family's primary concern, which is the fear of contracting the infection. This proactive approach provides education and reassurance, empowering the family to make informed decisions about visitation.
Promotes understanding and adherence to precautions: Clear instruction on how to don and doff personal protective equipment, hand hygiene techniques, and other infection control measures increases the likelihood that the family will follow the precautions correctly, reducing the risk of transmission.
Empowers the family to make informed choices: By providing knowledge and skills, the nurse enables the family to feel more confident in their ability to visit safely. This sense of control can help to alleviate anxiety and promote positive coping mechanisms.
Facilitates open communication and trust: The demonstration creates an opportunity for the nurse to answer questions, address concerns, and build rapport with the family. This open dialogue can foster trust and collaboration, which are essential for effective care.
Choice B rationale:
May provide false reassurance: While it's important to offer support and hope, it's not always possible to guarantee that family members will not contract the infection. Absolute reassurances could potentially lead to complacency or disregard for precautions, increasing the risk of transmission.
Fails to address the need for education: Simply stating that the family won't get sick doesn't provide them with the knowledge and skills needed to protect themselves and the client. This lack of understanding could result in accidental transmission.
Choice C rationale:
May pressure the family: Encouraging visitation without addressing underlying fears and concerns could be perceived as pressure, leading to resentment, anxiety, or even avoidance. It's important to respect the family's decision-making process and provide support regardless of their choice.
Doesn't prioritize safety: While emotional support is important, the primary focus should be on ensuring the safety of both the client and the family. Encouraging visitation without proper education and precautions could compromise safety.
Choice D rationale:
Focuses on compliance rather than understanding: Informing the family about legal mandates may come across as authoritarian and could potentially increase anxiety or resistance. It's more effective to focus on the rationale behind the precautions and emphasize their role in protecting both the client and the family.
Misses an opportunity to build trust: Simply stating the rules without engaging in dialogue may hinder open communication and trust-building. Taking a collaborative approach and addressing concerns can lead to better understanding and adherence to precautions.
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