No response = 1, Mobility: -Discuss and determine sitter availability Scenario 2 The oncologist is recommending Docetaxel as opposed to an orchiectomy. Waist belt restraint PRN; family sitter at bedside, assist with bath. The impedance per phase in the load ist 14+j1214+j 12 \Omega14+j12. Upon entering the room, the patient appears to be trying to get out of bed His VS are BP 122/64, P 89, R 12, SpO2 93%. Regular diet. No known allergies. Scenario 3 Attain fluids/fiber diet and assisted ambulation Hep-Lock in place left AC. Request sitter/family member to bedside Apical pulse rhythm: Regular Irregular Location: -Advise sitter to notify nurse when leaving the room Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. The pathology report shows no cancerous lesions. Wash and glove hands Anxiety True Senario 3 -Remove the dinner tray and make sure the diet is soft food. Evaluate understanding NPO with small amount of ice chips only. You are now preparing for discharge, place steps in order: Senario 1 Your responsibilities are: Scenario 1 DSD (dry sterile dressing), forehead laceration clean and dry intact. Pupils PERRLA, eyes clear. The ER nurse reports that his cardiac enzymes were borderline, (Troponin?, CK/CKMB?) Full assessment -Reassess patient q 5 minutes until awake, then 15 minutes until they are fully awake (not Drowsy). Failure to Thrive False. -Explain that Docetaxel is a hormone therapy that suppresses the testosterone that your testicles produce producing similar results as surgical intervention. 20ga. Temp 98, BP 114/67, P 115, RR 20, SaO2 98%. Provide a few chairs if possible for her family to also be comfortable No known allergies (NKA). Blood Pressure, 7a-7p Total: 7p-7a Total: -Obtain chest tube tray and set-up pleurovac Cryotherapy, which uses an endoscope to apply a cold liquid or gas to abnormal cells in the esophagus. Excess Fluid Volume, Risk for False Health Change Increased acuity Scenario 3 Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. He is currently febrile with temperature 100.8, HR 99, BP 135/96, RR 20, PaO2 96%, nauseated with no vomiting, rebound tenderness in right lower quadrant, has elevated WBC's and surgeon feels this will be uneventful even though he has just been diagnosed with AIDS this past week. Neuro WNL alert and cooperative. Temperature is now 102.8. He also states he is feeling weak. Elevate Extremity You take his vital signs which are: Temp 101.3, Pulse 88, Resp 24, B/P 116/84. Ineffective Renal Perfusion, Risk for True High fall risk. Mr. Richardson is requesting assistance to ambulate to bathroom. and the GI cocktail given in the ER did relieve his CP but not completely. Document results. Remind the nursing staff that the patient is NPO. We have more than 20 years' experience in the industry providing a quality service to our clients We pride ourselves on our customer-orientated service and commitment to delivering high end quality goods within quick turnaround times. Notify doctor and charge nurse Determine from medical record if partner is aware of his recent AIDS diagnosis. Combien gagne t il d argent ? This shop has been compensated by Inmar Intelligence and its advertiser. Record intake and output The patient is awake alert and oriented. No response = 1, Range of Motion: Full, Limited She is also to receive radiation, chemotherapy, and hormone therapy post operatively. Elevate head of bed Scenario 4 Skin warm and, dry, all vital signs in WNL except 115 pulse, which is normal for him. Neuro WNL. Acute Pain True He states, "This is not serious." Inappropriate words = 3 Scenario 3 Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. Amount: _______ Anxiety True Ask patient to explain to you what procedure she was expecting to have this morning. The patient states that the symptoms occurred in the middle of the night and woke him from his sleep. Heterotrophs include (1) autotrophs, saprophytes, and herbivores (2) omnivores, carnivores, and autotrophs (3) saprophytes, herbivores, and carnivores (4) herbivores, autotrophs, and omnivores. IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. Neptune is an average distance of 4.5109km4.5 \times 10^{9} \mathrm{km}4.5109km from the Sun. Educational Needs Increased acuity Combien gagne t il d argent ? Today's incentive spirometry Tidal Volume is 1250ml, improvement over yesterday's 900ml. Genitourinary Assessment Obtain translator Scenario 1 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. All opinions are mine alone. Vital Signs: B: 160/92, P: 96, R: 22, SpO2: 98, T: 98.9F, 37.1C. Wash and glove hands She has just been transported from recovery. Normal Sinus Rhythm on telemetry. Dr. Jones. LOC Normal acuity Shock, Risk for False Impaired comfort: True RLE: ______________ LLE: _____________ Anxiety False The 'Strandperle' (lit. Fall Risk Increased acuity PT to educate patient -Notify HCP of fall, complete incident report Scenario 5 Multiple abrasions, bruising Head, chest, and inner thigh. Bleeding, Risk for False Students will prioritize medical surgical . Fall, Risk for False Sa fortune s lve 2 216,00 euros mensuels Imbalanced Fluid Volume, Risk for True They wanted to know and pressure you for the information. Temperature is 98.3, HR is 87, RR is16, BP is 121/74, PaO2 is 98%. -Complete head-to-toe assessment while patient is on the floor. It was diagnosed by a portable X-ray and quickly splinted by the ER staff. Ms. Getts is being transferred as an emergency to Critical Care. Where is my camera man!! Senario 4 She is also investigating bone marrow transplantation. Neuro WNL alert and cooperative. Assist patient Impaired Mobility True Tibial: _____ + Bilateral Other: ______________ Generalized: Pedal: ______ + Bilateral Other: ____________ Sacrum: Non-pitting Pitting ___ +. -Have patient remain in bed, head elevated 30 degrees Offer nutrition/toilet If family/visitors come, will need education to airborne precautions. Scenario 1 Scenario 3 The heartburn has become worse since he started treatment for his URI. Tunneled, site _______________ Implanted port, accessed _____________________ Flexes & withdraws = 4 Readiness for Self-Care Enhancement True Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. The charge nurse tells you not to move the patient, because there is no special treatment according to social status. Her pitcher has already been filled three times this shift. The Swift River Nursing Simulation involves artificially representing real-world processes with sufficient fidelity to enable learning through immersion, practice, reflection, and feedback without facing the risks inherent in a similar real-life situation. Offer bedpan Document results/findings Inform patient about the progression and risk a PCP infection has for a patient with AIDS. -Assess if the contents of lunch tray are intact. Therapeutic communication. Mr. Gonzalez's repeat troponin was negative and no significant elevation in his other enzymes. The bed arrives tomorrow. Scenario 5 The emergency bathroom light goes off and the nurse finds Mr. Greer on the floor in the bathroom. Dysfunctional Gastrointestinal Motility False His children are visiting, and they are very supportive. You notice she is crying and is expressing fear that she "will always have this pain and numbness" and she doesn't think she can cope. Neck: ______________ Scenario 5 -Tell the wife that you will speak to the husband, and this is apprehension is expected with this surgery/diagnosis. Seek clarification -Start an IV Scenario 3 Electrolyte Imbalance True Document results and findings Pregnancy and labor and delivery are not typically associated with the concept of cellular regulation, Patient: Donald Lyles,52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. Consult Social Service Safety Acute Pain True Discription, Table 4 Cross-sectional, Longitudinal, and Sequential Developmental Designs, Engagement 1 Recognizing Research Strategies, A mental health worker with a Christian worldview.docx (Auto Recovered), NPO Breakfast: __________% Lunch ______________ %, Ethics and Social Responsibility (PHIL 1404), Care of the childrearing family (nurs420), Advanced Care of the Adult/Older Adult (N566), Business Professionals In Trai (BUSINESS 2000), Microsoft Azure Architect Technologies (AZ-303), Nurs & Healthcare I: Foundations [Lec] (NURS356), Accounting Information Systems (ACCTG 333), Bachelor of Secondary Education Major in Filipino (BSED 2000, FIL 201), Methods of Structured English Immersion for Elementary Education (ESL-440N), 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), C228 Task 2 Cindy - Bentonville - Passed with no revisions, Lesson 4 Modern Evidence of Shifting Continents, MMC2604 Chapter 1 Notesm - Media and Culture: Mass Communication in a Digital Age, Lesson 17 Types of Lava and the Features They Form, Lesson 9 Seismic Waves; Locating Earthquakes, Analysis of meaning and relevance of History from the millennial point of view, Entrepreneurship Multiple Choice Questions, (Ybaez, Alcy B.) The surgeon has suggested Androgen-deprivation therapy (ADT) with surgical castration (orchiectomy). Assess for bowel sounds Full assessment You arrive in room to check on her, after washing hands. You question her while reviewing her operative consent and determine that everything is correct. : an American History, EMT Basic Final Exam Study Guide - Google Docs, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. -Offer nutrition/toilet Mr. Greer is on the floor still but is awake and oriented and is complaining of back pain below his right scapula. Dyspnea at rest Dyspnea with minimal activity Use of accessory muscles Diet as tolerated. Offer assistance in providing more information about treatment options for newly diagnosed AIDS patients. Scenario 3 Evaluate/modify plan of care Scenario 1 Fall Risk Increased acuity Pain Level Increased acuity Encourage fluids Love and belonging- Educate patient Bleeding Risk for: False Procedure is canceled for the day and rescheduled later allowing for new consent. No known allergies (NKA). He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. Report and document results He asks to speak to a clergy member. Ineffective Airway Clearance True Discuss his understanding about the plan of care. Palliative care. Senario 3 You are told that he has intermittent chest pain with substernal burning that radiates to his mid-back. Call rapid response Inspect cast site Perform full assessment and provide anti-nausea medicine. In the interim, start an IV and start infusing Ringers Lactate. Vital sign assessments Scenario 3 Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room. Impaired Comfort True -Assess patients' pain and rule out cardiac pain. Infection, Risk for False Scenario 2 Scenario 1 Too bad the cruise area was a very unatractive part of the River Elbe. Scenario 4 What order are you providing the information to the receiving nurse? Scenario 1 Decreased Cardiac/perfusion False -When the HCP arrives, stay in the room to determine whether you can continue care with the patient His partner is not with him at this time but will arrive soon to facilitate his discharge home. The patient has a pneumothorax that requires a chest tube placement. Peripheral Neurovascular Dysfunction: False Love and belonging Mr. Dominec decides he does not want to see Infectious Disease doctor about his new cough. Family Health III-Pediatrics (NSG 6435) Emergency Medical Technician (EMS 1150) Applied Research In Business (MIS 781) Anatomy & Physiology I With Lab (BIOS-251) Molecular Biology (BP 723) Newest Marketing Management (D174) Professional Application in Service Learning I (LDR-461) Professional Capstone Project (PSY-495) Theology (104) Ms. Gestalt is now complaining of fever and chills. Perineal Care -Remove the lunch tray and ensure pre-operative consent has been signed. Use therapeutic communication/Active Listening Scenario 3 Apical Pulse Rate: Heart Sounds: Normal S 1 S 2 S 3 Use therapeutic communication/Active Listening Document results Monitor and evaluate fluid intake -Use therapeutic communication/active listening Constipation, Risk for True Renal diet. Chronic Sorrow False Health Change: Increased acuity Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulate to bathroom. Shock, Risk for: False Imbalanced Nutrition True -Ask Mr. Burgundy to lower his tone as it can be disturbing to other patients Offer assistance Verify call Light/bed safety precautions Mr. Duncan is now complaining of feeling "dizzy" when he stands. -Teach the patient that there are several interventions for complications post-prostatectomy to include erectile dysfunction, post-op prostatectomies, and self-care involved with a foley catheter at home. Vital signs -Temp 98.4,BP 178/105, P 112, RR 28, SaO2 94%; Neuro- WNL's. -Check patency of Foley catheter, urine color, and ensure it is secure to the patient's leg Mr. Dominec leaves the room and you discharge him and escort him and his partner to the car. Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (Hypercapnia). Yes Purposive Communication Module 2, Chapter 1 - Summary Give Me Liberty! Self-Care Deficit True Acute Confusion: True Sa fortune s lve 2 000,00 euros mensuels -Assess the patient's anxiety level while using therapeutic communication to decrease patients' stress. Localizes pain = 5 Use therapeutic communication/Active Listening Health Change Increased acuity Wash and glove hands -Ensure IV is patent, Lithia Monson Scenario 5 Hopelessness False. Fall Risk Increased acuity Skin: Warm/dry Clammy/diaphoretic Skin Turgor: Brisk Tenting Robert Sturgess Robert Sturgess 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. His past symptoms for three months have been that he noticed a slight hoarseness in speaking, a slight dry cough not related to a cold, and upon examination had a "pea-size lump on the center of his neck". Color:__________ nursing care plan for Linda Pittmon, a 74 -year old female patient who is a noncompliant diabetic, and frequently stays at the local homeless shelter. Scenario 5 Document Results/Findings Assessment of bowel movement Remain with patient Chronic Pain False He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care. Disoriented to time and place, speech slurred. Disoriented, confused = 4 Noncompliance True. Skin integrity at risk True Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Leave to break room and not continue in conversation. He also has metal fragments on his left side on his leg arm and torso. Impaired Skin Integrity, Risk for False Upon entering room, you wash/glove hands. Mr. Wright is pleasant and cooperative, but needs to be reminded to avoid pressure on his heel and sacrum. Scenario 4 Document results Senario 2 Ann Rails Wash and glove hands 2Provide comfort in pre-surgical room Mr. Dominec. Scenario 4 -Explain to the patient that he is now considered stable, you are taking him to the hallway, and he will be admitted to an impatient room within a few hours Notify lead nurse/doctor Scenario 1 Paul Greer Begin post op education for day one Use therapeutic communication/Active Listening Primary: Check LOC, Orientation, Breathing, Circulation, Brief Neuro assessment to include spinal pain or deformities, Obvious injuries. Dr. Suculo, Physiological You explain that his condition has worsened and now he has been taken to ICU. Scenario 5 Insert Foley catheter Sit at an eye level. Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. Scenario 5 Evaluate patient understanding Mr. Dominec had his surgical procedure and is doing great. Failure to Thrive: True. John Duncan, 56yr-old male, Dx- Gastroenteritis, returned yesterday from Cancun, c/o intractable diarrhea, weak, pale, and refusing to eat. NKDA Assessment The client vital signs are: Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%, Neuro WNL alert and cooperative. Safety When completing the shift change neuro check, you notice the patient's left pupil is sluggish. Senario 3 Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10. He was initially sedated with versed 2mg, and Fentanyl 100 mg by the EGD nurse, but the patient was not tolerating the procedure, so anesthesia was called to administer propofol. Assess for fall risk -Assess patient's understanding of the teaching and discuss home support, os de la main et de la ceinture pelvienne, Julie S Snyder, Linda Lilley, Shelly Collins. The sister of Mr. Mancia calls from home to speak with you. Scenario 4 Verify Call Light/Bed Safety precautions Self-Care Deficit: True Verify call light/bed safety precautions Assess food consumption and intake and output 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. Fatigue True Use therapeutic communication/active listening Students will form a preliminary assessment based on reported assessment data for medical surgical patients in a virtual clinical environment. -Complete incident report. Inform his partner that everything is being done to keep him comfortable. Fear/Anxiety True. Your response to all of them would be: Scenario 1 She is having some difficulty breathing. Odor: __________, *Types: Abrasion, Burn, Laceration, Puncture, Surgical, Pressure Ulcer, Vascular Ulcer, Maceration, Excoriation, Skin Use therapeutic communication/active listening ADA diet, intake, 25%. Evaluate understanding Isolative, appears fearful, crying, and refusing to see her husband. Yes Combien gagne t il d argent ? Ms. Cumble is in bed and appears comfortable and requests assistance from you to get out of bed to go to the bathroom. There is an order to apply a waist belt restraint if needed. Mr. Burgundy now has his cameraman filming in the ED and is attempting to do a live report. Contact dietary consult Senario 5 -Set-up for stat portable chest x-ray Impaired Skin Integrity, False Mrs. Pittmon states she has had numbness for years but "now I can't . Scenario 1 Deficient Diversional Activity False Alert and cooperative. Remain with Patient, Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). Prior to changing shift, you enter the patient's room to complete a full assessment, and Ms. Monson is now crying asking to for someone to take her home! List the nursing care order. Psychological Needs: Increased acuity Respirations Mr. Thomason appears now better oriented and MD arrives unexpectedly to examine him. -Ensure bed is in lowest position, and rails are in place The provider explains that it is a pre-cancerous stage in where the cell develops abnormal features. Acute Confusion True Pain Scale: 0 to 10: _______________ Pain Level Increased acuity Imbalanced Nutrition True You enter his room and recognize that Mr. Thomason appears to be talking to himself and appears confused.
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