The nurse is caring for a patient who is unconscious.
Which action by the nurse is appropriate?

Perform nursing tasks quickly to promote rest and decrease agitation.

Request that family members avoid touching the patient.

Turn the television to a loud volume to help with sensory stimulation.

Explain procedures to the patient in a normal tone of voice.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Performing nursing tasks quickly might compromise the quality and thoroughness of care. Unconscious patients still require careful and meticulous attention to their needs, and rushing could lead to errors or omissions in care.

Choice B rationale

Discouraging family members from touching an unconscious patient can be detrimental to the patient's well-being. Even in an unconscious state, patients may benefit from the familiar touch and presence of loved ones, which can provide comfort and potentially aid in sensory processing.

Choice C rationale

Turning the television to a loud volume is unlikely to be beneficial for an unconscious patient and could be overstimulating or even distressing. Sensory stimulation for unconscious patients should be carefully considered and usually involves gentle, controlled inputs rather than loud, indiscriminate noise.

Choice D rationale

Explaining procedures to an unconscious patient in a normal tone of voice is an appropriate action. Although the patient may not consciously understand, they may still have some level of auditory processing. Speaking calmly and explaining actions can also provide a sense of respect and dignity for the patient. .

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Correct Answer is D

Explanation

Choice A rationale

Hypokalemia, a deficiency of potassium in the blood (normal range: 3.5-5.0 mEq/L), typically leads to metabolic alkalosis due to intracellular hydrogen ion shifts. While respiratory and metabolic acid-base balances are interconnected, hypokalemia itself does not directly cause the retention of carbon dioxide, which is the hallmark of respiratory acidosis.

Choice B rationale

A high fever increases the metabolic rate, leading to increased oxygen consumption and carbon dioxide production. However, the body usually compensates for this by increasing the respiratory rate to expel the excess carbon dioxide. Therefore, while fever affects gas exchange, it is more likely to cause respiratory alkalosis due to hyperventilation, not acidosis.

Choice C rationale

Extreme anxiety can lead to hyperventilation, causing an excessive exhalation of carbon dioxide and a subsequent decrease in the partial pressure of carbon dioxide in the arterial blood (PaCO2). This results in respiratory alkalosis, not respiratory acidosis, where the PaCO2 is elevated (normal range: 35-45 mmHg).

Choice D rationale

Sedative overdose depresses the central nervous system, including the respiratory center in the brainstem. This depression leads to a decrease in both the rate and depth of breathing (hypoventilation). Inadequate ventilation causes the retention of carbon dioxide, leading to an increase in PaCO2 and a decrease in blood pH (normal range: 7.35-7.45), resulting in respiratory acidosis.

A. Play music the client chooses. B. Encourage visitors frequently throughout the day. C. Sit in a chair next to the client and talk. D. Turn on the television to the Super Bowl.

Correct Answer is A

Explanation

Choice A rationale

Playing music chosen by the client can promote relaxation by providing a familiar and comforting auditory stimulus. Music can help to reduce anxiety and create a calming environment, thus minimizing sensory overload in a client recovering from a stroke in the intensive care unit. This personalized approach respects the client's preferences and can positively influence their emotional state, fostering a more restful atmosphere conducive to healing.

Choice B rationale

Encouraging frequent visitors throughout the day can contribute to sensory overload for a client recovering from a stroke. While social support is important, excessive stimulation from multiple visitors can be overwhelming and disrupt the client's rest and recovery process in the intensive care unit, potentially increasing agitation and hindering relaxation.

Choice C rationale

Sitting in a chair next to the client and talking can be stimulating and may not promote relaxation, especially for a client who has recently experienced a stroke. Depending on the content and tone of the conversation, this interaction could increase sensory input and potentially cause agitation or fatigue rather than fostering a calm and restful environment needed for recovery in the intensive care unit.

Choice D rationale

Turning on the television to the Super Bowl would likely exacerbate sensory overload due to the bright lights, loud noises, and fast-paced visual stimulation. This type of environment is counterproductive to promoting relaxation and can be particularly overwhelming for a client recovering from a stroke in the intensive care unit, potentially increasing anxiety and hindering rest.

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The nurse is caring for a patient who is unconscious.Which action by the nurse is appropriate?

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The nurse is caring for a patient who is unconscious.
Which action by the nurse is appropriate?