Med-Surg SR Exam Study Guide Graded A 2024 With Verified Solutions Tim Jones - 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 - 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 - 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 - 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 - 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 diminish ed. 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 - 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 - 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 - 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
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