Exam (elaborations)
RS-Barkeley.
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Exam of 46 pages for the course EDPNA - technical at EDPNA - technical (RS-Barkeley.)
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RS-BarkeleyTim Jones - correct answer-Educational Needs: Increased acuity
Fall Risk: Increased acuity
Health Change: Increased acuity
Neurological: Increased acuity
Pain Level: Increased acuity
Psychological Needs: Increased acuity
Tim Jones - correct answer-Physiological-
Decisional conflict: False
Defensive coping: True
Disturbed sleep pattern: False
Ineffective health maintenance: True
Risk for post-traumatic stress syndrome: True
Risk for spiritual distress: False
Safety-
Isolation precautions: False
Risk for Injury at home: True
Tim Jones
Scenario 1
You begin your shift assessment w/ Mr. Jones
Scenario 2
Mr. Jones is scheduled for a full body CT scan. Mr. Jones stated to the nurse that he "was
scared to leave the room." Further questioning and clarification revealed Mr. Jones does not
want to be alone and is afraid of being hurt
Scenario 3
Later in the evening Mr. Jones falls on his way to the bathroom
Scenario 4
Mr. Jones is resting quietly in the bed, R 22, slightly labored, color pink. Eyes closed. Upon
assessment, Mr. Jones was noted to have bilateral wheezing, R 24, some use of accessory
muscles w/ respiration's, dullness to percussion in the left lower lobe, an an unproductive
cough. Based on assessment, nebulizer tx administered per MD orders.
Scenario 5
Mr. Jones is now more alert and states he does not see the point in living anymore and
wishes he would just die quietly. He asks to speak to a clergy member. He does not want to -
correct answer-Scenario 1
,Wash hands
Reassure pt that he is in a safe environment
Interviewing pt regarding need for hospitalization
Complete physical assessment
Notify charge nurse and social services
Scenario 2
Use therapeutic communication
Seek clarification from Mr. Jones on why he does not want to leave the room.
reassure Mr. Jones that he will be safe during his hospital stay
Administer prescribed anxiolytics medication prior to transfer to CT area
Offer UAP to accompany Mr. Jones during the CT process.
Scenario 3
Assess Mr. Jones for injuries
Assist Mr. Jones back to bed
Provide personal hygiene
Remind Mr. Jones to seek assistance before getting out of bed
Obtain a sitter to stay w/ pt.
Scenario 4
Notify HCP for change in respiratory assessment
Administer nebulizer to per HCP order
Reassess respiratory status
Encourage Mr. Jones to cough and take deep breaths hourly
Document findings from repeat assessment
Scenario 5
Talk w/ Mr. Jones about his wishes for end of life.
Call Mr. Jones' children per his request.
Ask Mr. Jones if he would like for a chaplain or minister to be called.
Discuss options w/ Mr. Jones regarding end of life care.
Notify the social worker of need for a new nursing home placement option.
John Wiggins - correct answer-Educational Needs: Increased acuity
Fall Risk: Increased acuity
Health change: Increased acuity
Neurological: Normal acuity
Pain Level: Increased acuity
Psychological Needs: Normal acuity
John Wiggins - correct answer-Physiological-
Acute pain: True
Deficient knowledge: True
Grieving: False
Impaired mobility, risk for: True
Nausea: True
,Safety-
Bleeding, risk for: True
Peripheral Neurovascular dysfunction: False
John Wiggins
Scenario 1
You respond to Mr. Wiggins call light. He is complaining that his headache is worsening. You
tell the pt that you must do a assessment before you can give him any medication. his
Glasgow coma scale is 15. his VS are BP 168/80, T 98.9, P 98, R 24. Complete the
neurological assessment.
Scenario 2
Your neurological assessment concludes the following: A/O x4 appears normal, left pupil is
slightly larger than his right and is +3 to react to light, there is no evidence of any drainage,
cranial checks are WNL, and extremity strength is slightly diminished. Glasgow coma scale
is 13.
Scenario 3
After sharing findings w/ the provider, he orders the following: 1. Contact radiology for a stat
CT scan of the head. 2. Start a saline lock. #. Neurological checks q30 minutes. 4. Hold
coding, administer Tylenol 1g 5. NPO
Scenario 4
You accompany transport of Mr. Wiggins from radiology back to his room. Yo - correct
answer-Scenario 1
Check for cognition A/O x4
Check pupils - equal and reactive
Check nose and ears for drainage
Check cranial nerves - smile, tongue, shoulder shrug
Assess extremity strength
Scenario 2
Explain to Mr. Wiggins why the pain medicine must be held.
Inform pt that you will discuss findings and pain medication w/ HCP.
Ask pt to remain in bed, and not get out of bed w/o assistance.
Put side rails up and call light in pts hand
Notify Physican and document
Scenario 3
Contact radiology for a stat CT scan of the head.
Inform the pt of the plan of care/stat CT, and administer Tylenol 1g.
Start a saline lock.
Inform pt why you are doing neurological checks q30 minutes and perform another baseline
neurological check
Inform the pt why he will no be receiving lunch
, Notify charge RN of deterioration of pt
Scenario 4
Remain w/ pt and turn him on his left side.
Call for help and initiate Rapid Response Team.
Note time when seizure began and duration.
Ensure IV access.
Reassess VS and neurological stats postictal.
Scenario 5
Assist anesthesia w/ their initial assessment and airway mgmt.
Administer Valium 5mg IVP
Initiate a 2nd 18g IV catheter and begin mannitol infusion.
Contact family and be present w/ HCP as he explains need for surgery to the family
Continue frequent VS and remain w/ pt, escort him to surgery
Joyce Workman - correct answer-Educational Needs: Increased acuity
Fall Risk: Normal acuity
Health Change: Increased acuity
Neurological: Normal acuity
Pain Level: Normal acuity
Psychological Needs: Normal acuity
Sensorium: Normal acuity
Joyce Workman - correct answer-Physiological-
Enhanced readiness for learning: True
Ineffective health maintenance: True
Safety-
Deficient fluid volume: False
Imbalance nutrition: True
Risk for injury: True
Social isolation: False
Joyce Workman
Scenario 1
Mrs. Workman presented to the diabetes clinic and provided a 24-hr food recall. She was
then sent to the lab for ordered lab tests. She is to notify the nurse upon return to the clinic
from the lab. Pt has requested more information on her diabetes and states she does not
understand why she "should be concerned" w/ blood glucose control in both the short and
long term.
Scenario 2
The nurse is providing information on nutrition to assist Mrs. Workman in managing her DM
II.
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