A 49-Year-Old Healthy Male Is Beginning to Emerge from General

question 7

Multiple Choice

A 49-year-old healthy male is beginning to emerge from general endotracheal anesthesia after a transurethral laser lithotripsy of the left ureter.He is restlessly turning side-to-side and moaning.During the hand-off report from the anesthesia provider and circulating nurse,the perianesthesia nurse learned that the patient will probably continue to pass "sludge" (small granular ureteral stone material) for the next hour.As the surgical team rushes back to the OR to start the next case,the perianesthesia nurse thanks them and tells them they can go,because she knows what is wrong with the patient and will take care of him.The perianesthesia nurse's comment reflects which phase of the nursing process and what will be her next actions?

• A) Her nursing diagnosis will prompt her to ask the patient to describe his pain.
• B) She is in the implementation phase as she checks the patient record for analgesia orders.
• C) She is in the assessment phase because she is not confident that the patient is awake enough to experience pain and continues to review vital signs and arouse him enough to speak.
• D) She has established a nursing diagnosis and is going to deliver the first dose on his patient-controlled analgesia pump to get medication circulating before he is fully awake.

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Definitions:

Acute Stress Disorder

A mental condition that develops within a month after exposure to a traumatic event, involving symptoms such as anxiety, nightmares, and flashbacks.

Stressful Event

An occurrence that causes significant strain or tension, requiring adjustment or response from the individual.

Severe Anxiety Reaction

A heightened state of overwhelming fear or discomfort, typically with acute physical and psychological symptoms.

Heart Rate

The number of heartbeats per unit of time, usually expressed as beats per minute (bpm).