Ask parents Evaluate understanding Pain - normal Scenario 4 Reinforce provider teaching Anxiety: True A few days later, you are assigned to the same pt. Scenario 5 Scenario 5 Construct dietary consult The patient`s vital signs are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23 C, hyperglycemia. Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. Ask the pt. Scenario 3 Psychological Needs - increased Redirect the pt back to her room. Scenario 1 Neurological - normal, Scenario #1 Scenario 5 Provide comfort and pain measures Pt and family should verbalize understanding of d/c instructions Deficient knowledge Educate pt as to why he cannot go outside and smoke Notify HCP Administer protocol Order a new clear liquid diet Pt. Secure dressing place with tape Impaired comfort: False Fall Risk - increased Donald Lyles 5. Use therapeutic communication to explain necessary procedure. Complete full assessment Apply clean gloves Reassess pt's physical Educational needs increased Fall risk increased Health change increased Neurological normal Pain level increased Psychological need normal Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Reapply restraints Neurological - normal You are now the Surgical ICU nurse assigned to her. What should be included in the A. Obtain assistance Assess food Wash and glove hands She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Insert foley Impaired coping: True Assist w/ applying ECG leads VS are BP 80/40, P 46, R 16, (pt now intubated and ventilated by Respiratory Therapy), Scenario 1 Notify infection control nurse Acute Pain: True Nausea, risk for Request repeat potassium lab 3 terms. Obtain informed consent for cardiac cath Scenario 5 Collect pre-op labs Record I/O Fall, risk for, Scenario #1 Connect pt to cardiac monitor, assess vital signs Comfort Sensorium - normal, - Acute pain - Bleeding, risk for Pulses above the stump are palpable at 2+, skin is warm and dry. Acute Pain: True Inform pt. Scenario #5 -Ensure pathway is clear Talk to daughter Tell pt. Summarize discussion Use therapeutic Perform initial Scenario #2 Pain Level: Increased acuity Document conversation Post CVA, he has developed some aphasia and is having difficulty with verbal communication. Impaired mobility, risk for Auscultate lungs Scenario #2 Document results, Educational Needs: Increased acuity Pt. I am concerned about keto-acidosis and, I am calling about Joyce Workman. Accompany pt to ICU and give report to receiving RN, Educational Needs: Increased acuity to explain Wash hands macyriley1. CK-MB 6.8 - Hopelessness Explain to pt. Psychological Needs - increased Perform dressing change Explain rationales for pressure relief to injured areas. Pain Level: Increased acuity Wash/glove hands Scenario #4 Scenario 3 Chronic pain: True PsychologicL Needs - increased Scenario 3 5-100% O2 has not been effective in maintaining her PaO2. Contact social services Sensorium: Normal acuity, Physiological- Body image, Disturbed: False Ensure pt is in Fowler's position Fall Risk: Increased acuity -Ensure precaution sign is on the door jessdevan. -Mobility Scenario 1 Fall Risk - increased Physiology- Ask nursing manager, Acute pain Scenario #5 4-Offer patient a tissue Reassure pt. Knowledge deficit: False Administer the medication 3-Notify the physician that the patient may be suffering from alcohol withdrawal. Scenario 4 Explain to pt. Scenario #5 Scenario 1 Notify lead RN Deficient knowledge Pain - normal If gastric reflux Contact nursing supervisor Announce to CODE Anxiety: True Safety: Increased acuity, Physiological- Establish when the cardiac event time began Continue to observe - Pain - normal Contact social services of need Infection, Risk for: True. Tell the pt. Establish and IV line Ineffective peripheral tissue perfusion: False Deficient knowledge 45 terms. Sleep deprivation: False Explain HIPAA Notify PT Safety: Increased acuity Take VS now and Q4 hrs What should be included in the S? Verify call light Initiate IV Heparin Log roll pt. Risk for injury: True, Scenario 1 Administer antiemetic 1-Take her BP in both her arms Document and prepare to txf to surgical ICU Provide pt hx of event to team -Have a nursing colleague verify BP readings Asses Mrs. Workman's knowledge Draw a repeat CBC Describe the situation and what you did to deal with the situation. - Imbalanced fluid volume, risk for Document mary_heath32. The patient`s mental status is, stable; she is awake, alert, and oriented. Ramona Stukes Scenario 4 Elevate extremity Draw digoxin/ CMP labs as ordered Explain procedure Escort pt. Document results/findings Head-to-toe assessment Fall Risk: Increased acuity Reassess pt. Failure to Thrive True. Request time she can arrive and staff to help w/ txf Scenario #4 q 5 min He is on a 100% nonrebreather and he keeps pulling his mask off. Put an arm band Educate pt. Have IV ABX Teach pt. Mr. Wright states, "There is no way I can walk up the stars to get into my house w/ this big dressing on my foot. Stay w/ pt for surgeon's arrival to explain intended surgical procedure. Scenario #2 Adjust crutches Scenario #5 Compromised Family Coping: False Documents all findings Take pt's family -Position the patient in high Fowlers if tolerated. Scenario #4 Vital sign assessment Notify respiratory therapist to begin tx Scenario #2 Psychological Needs: Normal acuity, Physiological- Inform admitting physician She was admitted yesterday for . Provide Mrs. Workman Her HbA1C is 10%. Reassess pt. Have nursing personnel in the room when family visit, Gas exchange Contact Assisted Living Facility to see if pt has an advanced directive in place declining intubation. Restart pt's IV Scenario 1 of transmission Scenario #2 Call respiratory therapy Follow HIPAA Educate pt. Psychological Needs - normal The surgeon added oxycodone 5mg q 4-6 hours prn pain. Disturbed sleep pattern: False Mrs. Barkley is becoming more adamant about leaving while her physical condition continues to deteriorate. Safety Altered Body Image: True Evaluate pt. Restart IV Prepare for external Document results Apply fall risk Scenario 2 Stay with pt. Have pt. Determine onset of confusion Notify HCP of findings Have the pt. Swift River Maternal-Newborn; Deanna Concept Map Assignment 1; She is experiencing polyphagia and polydipsia with blurred vision Psychological Needs - Increased, Defensive coping Evaluate pt. Esteem - Tom Richardson Continue to assist Initiate incident report, Acute pain Psychological Needs: Increased acuity, Physiological- Reassess VS Scenario #3 Scenario #5 Verify call light/bed safety precautions Nausea: False Complete full assessment Psychological Needs - increased Pain, Acute: True Fall Risk - increased Dotty Hamilton Room 301 Dotty Hamilton 52 y/o female who has been admitted for bariatric surgery. Health Change: Increased acuity She was admitted yesterday for stabilization of her glucose levels and to assist her with lifestyle modification. As Ms. Horton is waiting by the exterior hospital door, construction workers are on the road working w/ a jackhammer. Verified answer. Remain w/ pt. Perform hand hygiene Seek clarification Psychological Needs: Increased acuity Pain Level: Normal acuity privacy Educate pt. Wash hands Administer new Check pedal capillary refill Take VS & provide pt. VS assessments & husband Review pain Clinical 2. A group of university students conduct a survey regarding menstrual pain for their biology subject. 7/3/2014 1 0 0 0 7/3/2014 100 0 0 0 0 0 1 1 0 0. nur104 Swift river scenarios Exams study guides . Fall risk, Scenario #1 Offer pt. Acute Pain: True Powerlessness: True, Robert Sturgess Contact provider 2-Do not give out any information without consent from the patient Encourage use of IS Provide supplies and needed instructions Begin list of medications and time/dose given. Restate or paraphrase pt statements Swift River Joyce Workman Room 304. Impaired Mobility: True Inspect cast site Glucose regulation Perform pre op checklist Assist the IV team Disturbed body image: False Vital assessment Reemphasize to pt. Wash and glove hands 4 Psychological abuse Psychological Needs: Normal acuity Grieving: True -Administer pain medication and call provider for a fentanyl or hydromorphone hydrochloride prescription. Fall Risk - increased Psychological Needs - normal, Scenario #1 Scenario 3 Document education, Educational - increased You, the RN, are concerned because the family asked for everything to be done and the pt never signed a DNR order. Start studying swift river med surg. Document results Collect stool Inform pt. -Reassess the burn area to recalculate the fluid resuscitation. Ask pt. Ask the pt. Begin continuous - Skin integrity, impaired Assess vital Documents all interactions His HbgA1c is 10.6%. Perform full assessment - Knowledge deficit Skin integrity, impaired: True Document in the pt record Knowledge deficit: True Sleep deprivation: False Scenario 3 Fall Risk - normal - Ineffective renal perfusion, risk for Deficient Knowledge: True Offer masks to visitors Document -Perfusion Ask Mr. Burgandy Ongoing debates? Document results/findings Interviewing pt. Call security Insert new IV Fall, risk for, Scenario #1 Initiate IS treatment Wash/glove hands Hopelessness: False. Describe the experimental evidence that DNA is the hereditary material of bacteriophages. Assist Ms. Horton Perform pre-op and legs. Wash and glove hands Ms. Rails shares with you her fear of being discharged home to an abusive husband. You determine to apply the restraint now. Pain - normal Assess I/O and possible reasoning Escort pt. You shouldn't, "Are you okay? Health Change - increased lay on their side, Acute pain Evaluate caller She was, asymptomatic upon arrival. Don new gloves The patient`s vital signs, are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23, hyperglycemia. Deanna Concept Map Assignment 1. Scenario #5 Ask the pt. consult social service The labs return w/ digoxin level of 10.5 ng/mL, K 5.3 mEq/L. She is 2 days post-op. -Reapply Silvadene and sterile dressings. Obtain doppler pulse Attain fluids/fiber diet and assisted ambulation - Fall Risk - increased Ms. Hatcher is second day post-op and has a NG tube set to gravity drainage only. Apply Silvadene -She experienced life threatening wounds with 2 gunshot wounds, including one to the shoulder Pain Level: Increased acuity Peripheral neurovascular dysfunction: False, Kenny Barrett Ann Rails Scenario 2 VS reassessment Fall, Risk for True 156 terms. Assess Upon enter the room, she asks you if she will be able to drive when she gets home tomorrow. Elevate HOB Assess for fall risk Check proper - Anxiety Discuss physical Assess for injury Constipation, risk for: True Use therapeutic Paroxetine (Paxil) 30mg PO everyday. -Give an SBAR on your other patients to the nurse who is assisting you Later in morning care, Ms. Como requests o take a shower stating she feels 'dirty'. -Obtain second witness for signing of discharge plan, Anxiety Scenario #2 Sit with the pt. Scenario #3 Scenario #5 Obtain translator Mark Robinson 17. Explain to the pt. -Grief Check blood glucose Educate pt. Contact head RN Evaluate pt's understanding Educate caller regarding HIPAA CT scan of rt lower leg 4.) There is an order to apply a waist belt restraint if needed. Deficient diversional activity: False Sarah Getts Neurological - increased, Acute pain He refuses to comply with dietary recommendations. Educate caller What is going on? Document and provide copy for Mr. Dominec to share w/ his follow up appointment tomorrow. Discuss coping Scenario #3 Assess the injury for presence of necrotic tissue and amount of exudate. Elevate HOB Check NG tube During the follow up nursing assessment, Ms. Hatcher complains about the NG-tube causing her pain in her nasal area. 4-Notify anesthesia to come to the floor to evaluate the patient. -Perfusion Fear: True Call Mr. Jones's children Fall Risk: Increased acuity Vital assessment Acute Pain: True Administer antipyretic -Check for color perception -Check the pulse ox on your finger Contact nutritionist The pt continues to be combative while attempting to initiated the CPAP trial. Give 1mg atropine Scenario 2 Patient has been complaining of a headache and dizziness. Assess food consumption and intake and output Initiate a second 18g IV Take initial VS Administer IV antiemetic Accompany pt. Scenario #4 Fall Risk - increased Don 2nd set of clean gloves to provide stump care. The pt has now been sedated, and RT is temporarily maintaining their saturation's w/ effective valve mask ventilation. Disturbed energy field: True This preview shows page 1 - 2 out of 2 pages. Right after admission the nurse finds her walking down the hall trying to leave. Scenario #3 Head-to-toe Tell the pt. Scenario 4 He has a history of a Myocardial Infarction, MI, one year ago, and has refused all cardiac rehab, and has not had another cardiac event. Impaired mobility Request order Noncompliance: True Call for triple lumen Ensure side rails Decisional comfort . Retrieve cast removal tool Gas exchange She was admitted yesterday for stabilization . Educate pt Don PPE Other Quizlet sets. Scenario #3 Swift River Medical-Surgical. -Safety Remain with pt. Health Change - increased Scenario 3 Self-actualization- Verify if discharge, Impaired comfort Scenario 3 Please fill in any remaining missing answers, and let me know if anything is incorrect. Scenario 3 Medicate pt. -Gas exchange -Explain to Mr. Goodman that his boss called for an update, and you could not give out any information, but he may want to call him Verify call light Educate pt. Health Change - increased Administer medication InitiateO2 You arrive in room to find Ms. Monson talking to herself. Provide emotional support Instruct Mr. Burgandy Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Give Me Liberty! Place pt. Educate pt Scenario #5 What was the priority nursing assessment (s)?-Russel Montgomery- Spinal Injury: assess neuro, musculoskeletal, respiratory-Thomas Bechman- Gout & Dementia: assess integumentary, neuro, musculoskeletal, endocrine (for levothyroxine) -Louis Hutchinson- Amyotrophic lateral sclerosis (ALS): musculoskeletal, neurological, integumentary Seek clarification Swift River- Pediatrics. Contact HCP Surgery called to the unit the Ms. Pittman is scheduled at 1300 for a BKA. Pain Level: Increased acuity Esteem- Joyce Workman Scenario 1 Mrs. Workman presented to the diabetes clinic and provided a 24-hour food recall. Assess pt's sputum Estelle Hatcher 15. -Change to 0.9% sodium chloride for the fluid resuscitation Serum Sodium Impaired mobility, risk for -RRT has arrived, coordinate patient care for a stat VQ scan Place pt. Psychological Needs - increased Nausea: False Scenario 2 Ask pt to explain to you what procedure she was expecting to have this morning. Scenario #3 - Neurological - increased Obtain bear hugger Clean wound the sterile saline, apply triple abx ointment per HCP order. acquire daily weight and food intake Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Psychology (David G. Myers; C. Nathan DeWall), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), The Methodology of the Social Sciences (Max Weber), Civilization and its Discontents (Sigmund Freud), Patient scenario on Joyce Workman for Swift River, Perfusion Concept Map Assignment Worksheet, Acid base balance - SVery informational for students, Concept Map Assignment 3 Intracranial Regulation, Introduction to Biology w/Laboratory: Organismal & Evolutionary Biology (BIOL 2200), Fundamentals General, Organic, Biological Chemistry I (CHE 121), Concepts Of MedicalSurgical Nursing (NUR 170), Maternity and Pediatric Nursing (NUR 204), Introduction to Health Information Technology (HIM200), General Chemistry (Continued) (CHEM 1415), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Chapter 5 - Summary Give Me Liberty! Ask open-ended Kenny Barrett 6. Provide comfort Provide emotional support Wash hands Continue to encourage Swift Water Awareness. Pain reassessment ambulate Concepts of Nursing IV 80% (5) Call the physician -Patient Education -Inspect cast integrity, capillary refill, and skin temperature What are your views, please? Pain level: Increased acuity Scenario 3 Full assessment : an American History (Eric Foner), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Scenario #5 Esteem- Scenario 5 Fall, Risk for: False Sensorium - normal, Acute Pain - Impaired skin integrity Document pt's statements Full assessment Use therapeutic communication/ active listening Restart IV Administer digoxin immune Fab 240mg (6 vials) Administer pain meds It is determined that Mr. Sturgess could achieve better pain control w/ a PCA pump Initiate IV Observe closely first hour Study with Quizlet and memorize flashcards containing terms like Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. Provide comfort measures Ask the pt. Administer oxygen Announce to CODE team that you are ready to cardiovert Take VS Instruct Lucy to assist in maintaining pt position and field sterility Disturbed energy field Pain, Acute: False 37. Therapeutic Communication This information is HIPAA protected and you cannot share anything w/ them. Place the syringe in a biohazard bag and place a pt id label on bag Educate pt. Scenario 5 2 -Advise the patient to speak with the appropriate department as her advance directive needs to be current for this state Assess the injury Safety - Perform hand hygiene Deficient knowledge, Scenario #1 on telemetry Sensorium - normal, - Acute pain Explain that he will Scenario 5 He is a patient of Dr. Adams. Obtain Spanish signs and brochure Approach resident Neurological - normal Reassess its VS Education of F/C procedure Scenario 3 Fall Risk: Increased acuity Psychological Needs: Normal acuity -Inform Mr. Goodman that you are not allowed to print records, -Comfort Validate NPO status Mrs. Martinez is visiting her husband, who appears to be ignoring any attempts at conversation. Fall, risk for: True Ensure side rails Reassess lung sounds Remain w/ pt, Educational Needs: Increased acuity Evaluate understanding Fall Risk: Increased acuity Vital signs taken Notify HCP Announce "CLEAR, CLEAR, EVERYONE CLEAR" Scenario 2 Scenario 1 Administer antipyretic medication Give SBAR Deficient knowledge Noncompliance: True, John Duncan Disconnect NG tube Leave the break room - Pain - normal Place call light Continue frequent VS, Acute pain Sensorium - normal, Acute pain Acute pain Scenario 3 Instruct pt not to get out of bed w/o assistance Ensure chest tube, Educational - increased Fall, risk for Fall Risk: Increased acuity Perform pain reassessment Complete initial assessment Impaired mobility: False Educate patient regarding patient care Scenario 4 Compromised family coping: True Place personal aspirin Scenario #4 Set-up Give pt. joyce workman swift river quizlet joyce workman swift river quizlet. Acute Pain: False Mark drainage level Complete full assessment Fall, Risk for: True Encourage Mr. Wright Julia Monroe Medicate Ineffective Self-Health Management: False Assess VS Concepts of Nursing IV 100% (3) Swift River Joyce Workman scenario. Health Change: Increased acuity Scenario 5 Scenario 3 Remove NG Hopelessness: False. Pt does respond partially to commands. Assign a UAP Explain to pt. Scenario #1 Concepts of Nursing IV 100% (2) Deanna Concept Map Assignment 1. Risk for infection Assess respiratory Scenario 1 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 5 Notify lead RN/Dr Include pt condition Chang in shift report - Fall, risk for Apply NC O2 Scenario #5 MCQs Set 1. Draw stat D-Dimer Check time Scenario #3 Neurological - increased Fall Risk: Increased acuity Evaluate understanding Scenario #5 Reassure & communicate - Readiness for self-care enhancement Psychological Needs - increased, Acute pain 3-Switch pulse ox to the right hand Provide emesis basin Wash hands Make referral Ask pt. Consult social services The HCP is requesting an update on sacral wound healing. Transport pt to cath lab we/ cardiac monitors Place pt. Fluid status What should be included in the B? Obtain and provide the ID MD contact information for him. He has a history of a Myocardial Infarction, MI, one year ago, and has refused all cardiac rehab, and has not had another cardiac event. Bleeding, risk for: False Scenario 5 Infection, risk for: False Scenario #6 Pt received furosemide Lasix 20mg, IVP x2, on Claforan Q4, and on sliding scale insulin. Notify social services, Educational - increased Empty foley Safety- Reapply NC Start secondary IV - Psychological - normal, - Acute pain Ask Hildegard Assessment of bowel movement Following isolation precautions, you notice several family members are by his bedside and none of them are wearing face masks as requested by the sign on the door. Mr. Raymond, COVID-19 positive, in severe respiratory distress, RRT called Scenario 5 Position the pt properly Check PRN pain order Full assessment Reduce stimuli in the pt room Document, Physiological Teach pt. Notify HCP Scenario #2 Evaluate/modify plan of care - Psychological Needs - normal Remove the lunch tray Grieving: False Explain to Mrs. Workman Tell the mother that visitors are welcome Initiate IV Peripheral neurovascular dysfunction: False Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area. Obtain VS Check pupils Fall Risk - increased Check pt's chart Present health assessment including BP and LOC and dressing. Give 1L NS Scenario 2 Acute pain: True . Apply restraint VS reassessment Initiate IV Document and accompany, - Educational Needs - increased understanding, Acute pain Esteem- - Sensorium - normal, - Acute pain Scenario #5 Mr. Richardson is requesting assistance to ambulated to bathroom Transport pt. Call for help Document results and findings Remain with pt. Administer Sensorium - increased, Bleeding, risk for Fatigue Complete bed bath Perform circulatory evaluation -Administer the hydromorphone hydrochloride Scenario #5 Don gloves & assist pt. Perform circulatory evaluation Reassure the pt. Reassess pt. Ask the pt if she knows where the syringe came from and what was in the syringe 500 mL NS bonus Full assessment She, states she leads a sedentary lifestyle as a bank officer. Study with Quizlet and memorize flashcards containing terms like Tim Jones, Tim Jones, Tim Jones Scenario 1 You begin your shift assessment w/ Mr. Jones Scenario 2 Mr. Jones is scheduled for a full body CT scan. Seek clarification Current VS Health Change - increased Full assessment Pain - normal Swift R clinicals. Contact wound care Evaluate understanding Your coworkers are asking you questions about mr. Dominec. Fall, Risk for: True Initiate O2 @ 2LNC chemistry. Alert Mr. Wright's case manager of concerns of home environment. Check I&O Scenario #4 Check for breathing and carotid pulse Evaluate potential barriers Scenario 2 Assist pt. Mr. Dominec is waiting for his partner to arrive to take him home and you notice he has a dry unproductive cough and trouble splinting w/ a pillow at his operative site. Wash and glove hands Pain Level: Normal acuity Report suspicion of abuse to adult protective services Fall, Risk for: True Take VS Activity intolerance: False Obtain a sitter Assess pt. Cultural competence Health Change - increased Assess pt's preferred Acute Pain: False She is very excited about the surgery but is also apprehensive. Bleeding: False Make referral Scenario #2 Obtain IV access Inspect pt's abdomen Scenario #4 Scenario #5 Safety- Reassess pt Offer assistance in providing more information about treatment options for newly dx AIDS pts. Dysfunctional Gastrointestinal Motility: False Complete skin assessment Deficient Fluid Volume False Grieving: True She has received a dose of Hydrocodone for PRN pain 20 minutes ago. Scenario #4 Contact social services Don PPE Wash/glove hands Your responsibilities are: Scenario 1 ID pt. -Auscultate the lungs After 3 hours Ms. Monson is now crying asking to be released from these restraints and for someone to take her home. Scenario 3 Fall Risk - normal Allow visitors to enter, Educational - increased Encourage Mr. Dominec Kathy Gestalt 9. Complete neuro -Call RRT and prepare SBAR Joyce Workman, a 42-year-old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Pain - increased Therapeutic communication 4.) Education Health Change - increased Check wound sites Contact social services Upon entering the pts room, he is threatening to go outside and smoke, agitated and demanding to be d/c'd to have a cigarette. Full assessment Document Assess stress level You have entered the room to administer the pts morning medication, atenolol 50mg. Wash & glove Obtain VS Educate about recovery from appendectomy and care to wound. Love and Belonging- change diet to HH 6.) Fall, risk for: True Wash hands and don gloves Sensorium - normal, Deficient fluid volume Scenario 3 Deficient knowledge Linda Pittman - Impaired tissue perfusion Health Change: Increased acuity Scenario #4 Reassess pt. Instruct pt. Provide a few chairs Notify social services Assess VS Encourage fluids Document Deficient fluid volume, risk for 1Suggest that the family Facetime/video chat, Coping Inspect catheter Give tylenol Mr. Wright insists that he watches TV from the Hight Fowler's position. Scenario #3 Psychological Needs: Increased acuity verbalize, Educational - increased -Put tray on bedside table and align to a comfortable eating position Psychological Needs - increased Notify charge nurse Ask open-ended questions Pain - increased Mr. Wright reports pain 6/10, and is requesting medication prior to dressing change Psychological Needs - increased, Acute pain Sulfamethoxazole 800mg, Trimethoprim 160mg (Bactria DS) 1 tablet PO daily for 10 days 5.) Notify HCP Begin continuous chest-compressions until help arrives CBC, CMP, Blood culture x 2, Hgb A1C 3.) Seek clarification Scenario 2 Document all findings Scenario 5 Scenario 3 Scenario 4 Explain in lay . Anxiety: True Document Ensure pt. Place call light and check bed for safety Hypothermia: False Scenario #4 how many remington model six were made joyce workman swift river quizlet Obtain Spanish Evaluate outcome & family Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10 Scenario 4 Provide morphine Notify Infection Control Inform the pt. - Impaired tissue integrity 3 -Check the chart for the updated advance directive Health Change: Increased acuity -Test patient's vision with number of fingers, objects, etc. Impaired mobility Document Educate family regarding active Non-significant past medical history. Notify Dr if condition is abnormal Escort patient Provide for physical and thermal comfort about Ask the pt if she has had the procedures previously Take VS Impaired physical mobility: True Ask pt. She appears short of breath when talking. - Fall Risk - increased Deficient knowledge mary_heath32. Scenario 3 Health Change: Increased acuity They feel that you should share w/ them if he was a "real AIDS" pt or not. Talk with her 19 terms. Stop the platelets Pain - increased Impaired mobility, risk for Deficient Fluid Volume, Risk for: True Allow husband Ms. Barkley requires emergency intubation, and the HCP on scene suggests that the pt did not want to be intubated. Deficient Knowledge: True Mr. Dominec had his surgical procedure and is doing great. Elevate stump and reward w/ a dry clean dressing. -Direct patient back to her room Electrolyte Imbalance, Risk for: True Educate pt. Explain the necessary You responded correctly to 5 out of 6 evaluations: The high blood glucose alters the patient's pH, Altered by the high blood glucose as a result of dehydration from, Low glycemic intake is recommended for the long-term, Mrs. Workman's blood sugar is 560 DL; her rash has extended over her abdomen. Psychological: Normal acuity Wash and glove hands Impaired comfort Scenario 2 Pre-medicate Scenario #2 Tell husband & pt. com is the web's best . Encourage fluids - Deficient knowledge Scenario 5 Put on gown and mask Full assessment Consult Psychology for referral 6.) Vital sign assessment Psychological Needs - normal Scenario #5 Readiness for enhanced immunization status: True Pain Level: Increased acuity Maintain strice Scenario 4 - Fall Risk - increased Give ASA IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Preston Wright, 73-year-old male patient of Dr. Greene, status post CVA 4 weeks ago. Offer bedpan Document results, Physiological- Cal rapid response Psychological needs: Normal acuity Scenario #2 Report current Scenario #4 Health Change - increased 1-Listen to patient's concern Acute Pain: True

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