ICU Related MCQ Quiz

Based on the patient's medical history of heart disease, ischemic attacks, and hyperlipidemia, it is likely that the patient is experiencing an ischemic stroke. Ischemic strokes occur when there is a blockage or clot in the blood vessels leading to the brain, resulting in decreased blood flow and oxygen to the brain. This can cause symptoms such as aphasia, decreased consciousness, and weakness on one side of the body. Hemorrhagic strokes, subarachnoid hemorrhages, and intracerebral hemorrhages involve bleeding in the brain and would not be consistent with the patient's medical history.

The patient's confusion and physical defensiveness suggest that they may be experiencing hypoxia. Hypoxia occurs when there is a lack of oxygen supply to the body's tissues. This can lead to confusion and defensive behavior as the brain and other organs are not receiving enough oxygen to function properly. Fear and anxiety may also be present, but the primary concern in this case is hypoxia. Pain is not mentioned in the initial assessment and, therefore, is less likely to be the cause of the client's symptoms.

The presence of vomiting that resembles coffee grounds suggests that the bleeding is occurring in the upper gastrointestinal (GI) tract. This can be due to the breakdown of blood in the stomach, which gives it a coffee ground-like appearance. Bleeding in the large intestine (colon), small intestine, or rectum would not produce this specific symptom.

The nurse should immediately notify the doctor and check the vitals of the patient. The patient's severe epigastric pain that spreads over the entire abdomen, along with the pallor and lying on the side, could indicate a potentially serious complication such as a perforated gastric ulcer or internal bleeding. Therefore, it is crucial to inform the doctor promptly and assess the patient's vital signs to determine the appropriate course of action.

The patient should be monitored for hematemesis and melena because these symptoms are indicative of gastrointestinal bleeding. Hematemesis refers to the vomiting of blood, while melena refers to the passage of dark, tarry stools that contain blood. These symptoms suggest that there is bleeding occurring in the gastrointestinal tract, which can lead to a potentially life-threatening condition. Monitoring for these symptoms allows healthcare providers to promptly intervene and manage the patient's condition to prevent further complications.

Elevating the head of the bed is the most rational nursing intervention for a patient with a diagnosis of ineffective airway clearance and an inhalation burn injury. This position helps to promote optimal lung expansion and ventilation, allowing for improved oxygenation and clearance of secretions. It can also help reduce the risk of aspiration and further complications. Encouraging coughing, monitoring respiratory rate and breathing, and monitoring oxygen levels are important interventions as well, but elevating the head of the bed directly addresses the airway clearance issue.

The correct order of the abdominal assessment is inspection, auscultation, percussion, palpation. Inspection involves visually examining the abdomen for any abnormalities or visible signs. Auscultation is the next step, where the healthcare provider listens to the bowel sounds using a stethoscope to assess the functioning of the gastrointestinal tract. Percussion follows, which involves tapping on the abdomen to assess the density of underlying organs and detect any abnormal masses. Finally, palpation is performed by gently pressing on the abdomen to feel for any tenderness, masses, or organ enlargement.

Aspirin should not be given to a patient who has been admitted with an ischemic stroke and has already been given a recombinant tissue plasminogen activator (rtPA) in the ER. This is because rtPA is a thrombolytic medication that helps dissolve blood clots, while aspirin is an antiplatelet medication that helps prevent the formation of new blood clots. Giving aspirin along with rtPA could enhance the risk of bleeding complications. Therefore, aspirin should be avoided in this case.

Acute pancreatitis is characterized by the premature activation of inactive digestive enzymes within the pancreas. Normally, these enzymes are only activated in the small intestine to aid in digestion. However, in pancreatitis, they become prematurely activated within the pancreas itself, leading to inflammation and damage to pancreatic tissue. This alteration in the normal physiological process is the key feature of acute pancreatitis.

Acute liver disease can lead to increased ammonia levels in the body. The liver is responsible for converting ammonia into urea, which is then excreted in urine. When the liver is damaged, it may not be able to effectively convert ammonia, resulting in its accumulation. Increased ammonia levels can cause symptoms such as confusion, lethargy, and even coma. Therefore, in the case of acute liver disease, it is true that there will be increased ammonia levels.

Esophageal varices can be caused due to portal hypertension. Portal hypertension refers to high blood pressure in the portal vein, which carries blood from the digestive organs to the liver. When there is an obstruction or increased resistance to blood flow in the liver, such as in liver cirrhosis, it can lead to an increase in pressure in the portal vein. This increased pressure can cause the veins in the esophagus to dilate and become varicose, leading to the development of esophageal varices.

The patient is at risk for hypovolemic shock because acute pancreatitis can lead to inflammation and damage to the blood vessels, causing fluid to leak into the abdominal cavity. This can result in a decrease in blood volume, leading to hypovolemic shock.

Administering an antiemetic to prevent vomiting can help prevent sharp spikes in intracranial pressure (ICP) and surgical hemorrhage. Vomiting can increase ICP due to the increased pressure in the abdomen and chest during the act of vomiting. This increased pressure can also lead to surgical hemorrhage, especially in patients who have undergone neurosurgery. By administering an antiemetic, the nurse can help prevent vomiting and subsequently reduce the risk of ICP spikes and surgical hemorrhage.

Acute liver damage can lead to cardiac dysrhythmias and respiratory failure. This is because the liver plays a crucial role in detoxifying the blood, producing proteins necessary for blood clotting, and metabolizing medications and toxins. When the liver is damaged, these functions are compromised, leading to a buildup of toxins and metabolic imbalances in the body. This can disrupt the normal functioning of the heart and lungs, resulting in cardiac dysrhythmias and respiratory failure.