Fall, Risk for True Scenario 3 Grieving: True Ineffective Coping False Obtain Spanish signs & brochure Use therapeutic communication/Active Listening Wash and glove hands -Ask the patient if it is okay to discuss his care in front of his children. Nr 325 final exam quizlet chamberlain - gqqa.wikinger-turnier.de Nutritional Intake: Adequate Inadequate BMI: Crutches at bedside adjusted for height. Psychological Needs Increased acuity 50% intake. Temperature spiked during the night to 102.4, BP now 146/94 which is slightly elevated, respirations at 30 bpm and slightly labored, heart rate 102 versus 84 from last night shift. Extends abnormally = 2 Perform pain re-assessment After 3 hours, Ms. Monson is now crying asking to be released from these restraints and for someone to take her home! Listen to patient concerns Water/Flush: Neuro WNL alert and cooperative. Scenario 4 Document results Establish second IV When a physician makes an incision into a body cavity just superior to the diaphragm and inferior to the neck, what body cavity will be exposed? His original lymph node biopsy was negative. Pain re-assessment Noncompliance False Attempt to orient to person, place, and time Remain with Patient, Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). Fall Risk Increased acuity Provide emotional support. Diet as tolerated, up ad lib after gait training. He is emotionally distraught and is insisting that he be allowed to report what is going on from the ER. Full assessment Impaired Mobility, Risk for True Acute Confusion: True Notify doctor Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. Document results/findings If family/visitors come, will need education to airborne precautions. Lung sounds are worse. You correctly diagnosed 11 out of 16 options. No known allergies (NKA). Acute pain: False Tom Richardson, 46yr-old. Allergic to sulfa drugs. Assist patient Put the patient on O2 NC and Fentanyl 25mcg IVP for pain. Deficient Diversional Activity False Notify doctor for Foley catheter Virginia Smith, 57-year-old who has elected to have a total mastectomy based on consultation with her surgeon, a total mastectomy removes all breast tissue but leaves all or most of axillary lymph nodes and chest muscles intact. Today, clubs like Hamburg City Beach Club, Lago Bay, Hamburg del Mar and StrandPauli provide a relaxed summer atmosphere with a view over the Elbe. The pathology report shows no cancerous lesions. Reassure patient of options Decisional Conflict True Wash and glove hands Family arrive one hour after event to his prior room and find Mr. Thomason's room is empty and have no idea of the events that have just occurred. Disoriented to time and place, speech slurred. Then the bus splashed into the river for a cruise. Document results Scenario 5 Combien gagne t il d argent ? Since the finding was low-grade dysplasia and is considered the early stage of precancerous changes, the gastroenterologist recommends another endoscopy in six months, with additional follow-up every six to 12 months. This will treat any cancer that may have metastasized to the bone. -Reassess patient q 5 minutes until awake, then 15 minutes until they are fully awake (not Drowsy). Continent: Yes No Occasional Incontinence Frequent Incontinence Brief His CP is 7/10 and his BP is 165/96, P 92, R 18, SaO2 98 on 2L NC. Sitting, BP 109/60, P 114, Standing the patient becomes very lightheaded and the nurse has them lay back down. NPO with small amount of ice chips only. -Restart the IV and draw CBC The oncologist is recommending Docetaxel as opposed to an orchiectomy. Scenario 2 -Perform neuro assess Document results Senario 1 Inspect cast site Impaired Skin Integrity False Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Pain = 2 Isolative, appears fearful, crying, and refusing to see her husband. Because of the fall the provider has recommended that he stay in the hospital another night. You enter patient's room. Neuro WNL's, alert and cooperative. Senario 4 Senario 2 3Check surgical consent for correct procedure and make sure operative site is marked. It is now two weeks later; Mrs. Smith has returned. 1. Ambulates with minimal assistance. The charge nurse tells you she will send someone to assist you, and to get out 2mg of Versed to have ready to sedate the patient at time of procedure. Fortune Salaire Mensuel de Ubah Kalimat Efektif Online Combien gagne t Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Urination: WNL Burning Frequency Urgency Skin warm and dry, all vital signs in WNL Combien gagne t il d argent ? You determine to apply the restraint now. ExplanationAnxiety/ fear True Palliative care. Document results and findings This shop has been compensated by Inmar Intelligence and its advertiser. Disoriented, confused = 4 Notify family as to when they may come and visit. Temperature is now 102.8. Provide comfort in pre-surgical room Mr. Dominec. IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. Senario 1 Bleeding Risk for: False Ms. Cumble states that she has not had a BM for three days. Nausea: False Failure to Thrive True. Ambulates with assistance. Impaired Home Maintenance Management False Senario 5 Some hair on the left side of his head has been burned off, as well. Patients vital signs are BP: 100/58, P: 106, R: 28, PaO2: 92%, T: 97.1 F, 36.2 C. He chooses to go home and see the doctor tomorrow in his office. PT to educate patient Upon assessment, you determined that she is confused to person, time, and place but is easily directable. Gown and mask Scenario 4 Inform his partner that everything is being done to keep him comfortable. If patient statement differs from the surgical consent she has signed, notify surgeon immediately Educational Needs Increased acuity Call Rapid Response protocol initiated Impaired Comfort True She is also to receive radiation, chemotherapy, and hormone therapy post operatively. Following isolation precautions, you notice several family members are by his bedside and none of them are wearing face masks as requested by sign on door. Scenario 3 Wash and glove hands Use therapeutic communication/active listening What order are you providing the information to the receiving nurse? Self-Care Deficit: True Scenario 5 Scenario 4 Blood, Glucose 185, 4 units of insulin sliding scale for coverage. Electrolyte Imbalance, Risk for True Document results and findings Scenario 1 The patient has a pneumothorax that requires a chest tube placement. The oncologist is insistent that the treatment begin immediately. Acute Pain True No response = 1, Mobility: Respiratory Rhythm: Regular Rhythmic Irregular Periods of Apnea Cheyne-Stokes Notify Physical Therapy (PT) Dr. Levine, Marcella Como, 38 yr-old, Sexual Trauma Victim (Rape), unknown assailant. Vital signs -Temp 98.6, BP, Erma Willis, a 65-year-old woman with a history of adenocarcinoma and multiple past episodes of related secondary infections, was admitted to the medical-surgical unit this morning with a diagnosis, Reflective Journal VCBC Post work Cellular Regulation VCBC Post Work Start Assignment Due No Due Date Points 10 Submitting a file upload Please submit your post work to Canvas within 48 hours of, Typically the concept of cellular regulation Involves the study of cancer and related diagnoses. Contact Social Services Expresses fatigue, fear, concern, and desire for recovery. Safety Scenario 2 Therapeutic communication -Assess patients' pain and rule out cardiac pain. ADA diet, intake 25%. Visual assess Your response to all of them would be: Scenario 1 Your coworkers are asking you questions about Mr. Dominec. Allow husband to come into recovery for a quick one-minute visit. Temp 98, BP 114/67, P 115, RR 20, SaO2 98%. Scenario 2 -Assess for fall risk Non-significant past medical history. Cross), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Week #7 Assignment - Incentive Spriometer . Impaired comfort: True Medical Surgical Flashcards | Quizlet He is aware that he may not have an erection and may need depends for bladder incontinence. Esteem The patient has a Foley catheter in place and is reporting 8/10 incisional pain and he is asking why his throat is sore. Regardez le Salaire Mensuel de New King James Bible Download For Windows 7 en temps rel. This information is HIPAA protected and you cannot share anything with them. Dr. Donofrio, Chronic Pain, Risk for constipation, impaired nutrition, anxiety, fear, grieving, hopelessness, powerlessness, Daily Flowsheet & Physical Assessment, Vital Signs Intake & Output Scenario 4 Impaired Skin Integrity, Risk for False Use therapeutic communication/Active Listening is a 57 y/o who has been admitted for a radical prostatectomy. Senario 3 Shock, Risk for: False Administer protocol antidiarrheal medication r/o Tuberculosis. When the nurse enters the room later that day to inform him that the procedure is scheduled for 1430, they see Mr. Gonzalez is sitting in front of a lunch tray. Wound site clean, dry and intact NPO, NG-tube to low continuous suction. Patient and family upset regarding dx. Medical-Surgical - Swift River Online Learning Reorient Patient to person, place, & time Sensorium Normal acuity, Physiological The nurse performs tilt test, Patient vital signs lying flat, BP 118/62, P 92, R 20, T 98.5, SpO2 97. BP 154/89, P 94 F, R 22, T 98.3F, SaO2 95% on room air. Pain, Acute True The surgeon believes that the surgery was successful but recommends the patient have chemotherapy and radiation postoperatively. Bowel sounds: Active, Hyperactive, Hypoactive, Absent (listen for full 5 minutes) Scenario 4 Nathaniel Gonzalez Fall, risk for: True Scenario 4 Hx of dementia, from nursing home, fall one day ago. Scenario 1 Health Change Increased acuity He is excited and tells the nurse he is starving and glad that he finally gets to eat. Palliative care. Re-assess patient Impaired Mobility False Check pedal capillary refill Scenario 4 Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Scenario 4 Toggle navigation Swift River.