Free ABPANC Behavioral Health/Cognitive Needs Questions and Answers — Questions and Answers
Question 1: A patient in the PACU is waking up after anesthesia and begins crying and asking repeatedly, “What happened to me?” What is the nurse’s best response?
- “You’re in the recovery room, and everything is fine.”
- “You’re safe here; you had surgery, and you are recovering well.” (Correct answer)
- “Don’t worry; you’ll feel better soon. Try to relax.”
- “You’re just confused from the anesthesia. You’ll remember soon.”
Correct answer: “You’re safe here; you had surgery, and you are recovering well.”
Patients waking from anesthesia often experience confusion, anxiety, and disorientation, a state known as emergence delirium. The best nursing response is to provide simple, clear, and reassuring information that reorients them to their current situation. Stating "You’re safe here; you had surgery, and you are recovering well" addresses their immediate concerns about safety and what happened, without overwhelming them with too much detail, helping to calm and reorient them.
Question 2: A child scheduled for ambulatory surgery begins to cry and refuse to go into the operating room. What is the most appropriate intervention by the nurse?
- Firmly tell the child they must cooperate so the surgery can proceed.
- Allow a parent to accompany the child to the OR if permitted. (Correct answer)
- Distract the child with toys or videos to reduce fear.
- Ignore the crying since it is normal for children to be scared.
Correct answer: Allow a parent to accompany the child to the OR if permitted.
Children often experience significant anxiety and fear when separated from their parents, especially before surgery. Allowing a parent to accompany the child to the operating room, if hospital policy permits, provides comfort and reduces distress, promoting a smoother induction of anesthesia. This approach supports the child's emotional well-being and can lead to better cooperation.
Question 3: A post-anesthesia patient begins exhibiting signs of delirium, including restlessness and pulling at IV lines. What is the nurse's priority action?
- Restrain the patient to prevent harm.
- Assess for hypoxia, hypoglycemia, or pain as contributing factors. (Correct answer)
- Provide sedation to calm the patient.
- Ignore the behavior, as delirium often resolves spontaneously.
Correct answer: Assess for hypoxia, hypoglycemia, or pain as contributing factors.
Post-anesthesia delirium is often a symptom of an underlying physiological imbalance rather than a primary psychiatric issue. Hypoxia, hypoglycemia, and uncontrolled pain are common and reversible causes that can manifest as agitation and confusion. Prioritizing assessment for these factors allows for targeted intervention and resolution of the delirium, ensuring patient safety and appropriate care.
Question 4: A patient recovering from surgery is anxious and expresses concern about returning to work due to financial stress. What is the nurse’s most appropriate response?
- “Let’s focus on your recovery first; you can worry about work later.”
- “I understand your concern. Would you like to talk to a social worker for assistance?” (Correct answer)
- “You should take all the time you need off work to get better.”
- “You’ll probably feel better tomorrow, so you can get back to work soon.”
Correct answer: “I understand your concern. Would you like to talk to a social worker for assistance?”
This response acknowledges the patient's anxiety and validates their concerns about financial stress, which can significantly impact recovery. Offering a referral to a social worker demonstrates empathy and provides practical support by connecting the patient with resources specifically designed to address such issues. This holistic approach supports the patient's overall well-being beyond immediate medical care.
Question 5: An elderly patient in Phase I recovery becomes agitated and repeatedly asks for their spouse, who has passed away. What is the most therapeutic nursing response?
- “Your spouse isn’t here. Do you remember that they passed away?”
- “You’re just confused from the anesthesia. Try to rest now.”
- “I can see you’re worried. I’m here with you, and you’re safe.” (Correct answer)
- “I’ll call your spouse to come as soon as possible.”
Correct answer: “I can see you’re worried. I’m here with you, and you’re safe.”
In situations of post-anesthesia confusion or delirium, especially when a patient is disoriented to time and reality, direct confrontation or correction can increase agitation. A therapeutic response involves validating their emotion, providing reassurance of safety and presence, and gently reorienting them to the current environment. This approach promotes comfort and reduces distress without reinforcing false realities.
Free ABPANC Behavioral Health/Cognitive Needs Questions and Answers
A patient in the PACU is waking up after anesthesia and begins crying and asking repeatedly, “What happened to me?” What is the nurse’s best response?