year-old female who presents to the Diabetes Clinic with a new. Risk for social isolation: False, Jose Martinez 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 4 Wash hands Notify family Secure dressing place with tape We need to stop the bleeding Notify family Nutrition Scenario #4 Deficient knowledge Ensure no one in the room is touching the pt or the bed and cardiovert Therapeutic communication She is very excited about the surgery but is also apprehensive. Kathy Gestalt 9. Wash & glove Full assessment Obtain a sitter She was admitted yesterday for stabilization, of her glucose levels and to assist her with lifestyle modification. 93 terms. Explain to pt. Remain w/ pt. Mr. Sturgess does not have a living will or durable power of care completed. Arthur Thomason 16. Scenario 2 2-Have the patient rest in the same position and repeat BP assessment in 15 minutes Fall - increased Document and provide copy for Mr. Dominec to share w/ his follow up appointment tomorrow. Nausea: False Ineffective Coping: False Accompany pt. Drug therapy: True She is also anxious as a result of recent surgery. Neurological: Normal acuity Deficient knowledge: True Monitor for adverse effects Provide emotional support -Wound Cultures Initiate I&O Ambulates with minimal assistance. Evaluate pt's understanding Scenario #3 Scenario 2 Scenario #5 PT to educate Obtain informed consent for cardiac cath Attempt to restart IV Increase supplemental O2 Wet to dry dressing w/ triple abx ointment to wounds. Discuss willingness for alternatives to smoking you take his vital signs which are T 101.3, P 88, R 24, BP 116/84 Obtain additional support Introduce hospital liaison, Acute pain Initiate IV Health Change - increased Review pain medication order Discuss options Assist pt out of bed Check for breathing and carotid pulse Pt. Place pt. Scenario #5 She has active bowel sounds Wash hands I suggest 10 units of regular. Document Notify doctor Infection, risk for, Scenario #1 -Have the next of kin sign the operative consent if available. Scenario #2 Acute confusion Scenario 2 Retake VS (BP 110/70, P 94) Notify the physican of assessment findings and await further orders Allow for non-compliance Advanced Medical Surgical Nursing New Patients Draw a repeat CBC Document Scenario 4 Document findings/results, Physiological- Verify if discharge, Impaired comfort Obtain telemetry set-up and take to pts room Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room Educate pt. Scenario #4 Ann Rails Impaired physical mobility: True Instruct pt. 1-Introduce and sit down by the patient's bedside Pain - increased Contact radiology Medicate pt. Scenario 3 Reassure pt. Educate pt-STD's and pregnancy Dr. Brown gives orders to remove NG-tube set to gravity and to begin a clear liquid diet Scenario #3 Scenario #5 Notify lead RN Pain Level: Increased acuity Report and document results Sexuality, Scenario #1 Pain - increased Scenario 4 Assess pt's preferred Liracross21. Inform Mr. Burgandy -Ensure there is no fingernail polish on the pulse ox Educate pt. Use therapeutic Failure to thrive. VS assessments Scenario 2 Assess current pain Scenario #4 Complete neuro Remove the dinner tray Sensorium: Increased acuity, Educational Needs: Increased acuity Her skin is warm and dry. Fall Risk: Increased acuity Inform pt. Marcella Como is now more talkative and shares with you that she is going to cooperate and wants to press charges against the assailant. Encourage to ambulate Scenario #2 4.) Check pupils Scenario 5 Guide her back Safety- Assist pt. Explain to pt. Assist the IV team Pt. Have pt. HCP orders digoxin immune fab to be given. Wound site clean, dry and intact NPO, NG-tube to low continuous suction. Obtain VS Assess documented pain She was admitted yesterday for stabilization of her glucose levels and . Perform pre op checklist Obtain an order Position the pt properly Document consults, Educational - increased Family at beside. Troponin 1.0 mg/mL Re-assess pt -Position the patient in high Fowlers if tolerated. Check I/O for possible dehydration Full assessment -Assess level of help needed Secure sitter to stay w/ Ms. Barkley after the insertion of the new IV. Scenario 4 Have pt put on a mask Document Infection, fisk for, Scenario #1 Request the uncle participates exam 3. Assess food consumption and intake and output Notify PT You discuss this cough Ineffective Self-Health Management: False Explain to Mr. and Mrs. Martinez the disease recess following a MI Scenario 4 Stop marking it as incomplete or missing info! Scenario 4 Pre-medicate for pain w/ prescribed medication Sensorium - normal, Impaired coping Kenny Barrett, 64 years old, was admitted for observation of initial administering of BP his treatment with blood pressure of 220/124 after visiting his doctor for a routine physical. Wash and glove hands Mr. Duncan is now complaining of feeling "dizzy" when he stands Scenario 2 : an American History (Eric Foner), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. - Impaired tissue perfusion Safety: Increased acuity Scenario #5 Provide a few chairs if possible for her family to also be comfortable Provide comfort Request sitter/family member to bedside Psychological Needs - normal Sensorium - normal, Deficient fluid volume Have nursing personnel in the room when family visit, Gas exchange Educate pt Anxiety: True Day 2 SBAR 3 vClinical - S Name: Joyce Workman ituation B Remind surgeon & staff Educate pt. Full assessment Evaluate pt understanding Connect pt. 1 Ask for a copy of the advance directive Educate pt. Obtain 16 gauge angiocath Inform the pt. Disconnect NG tube Disturbed energy field: True Assis pt. Impaired comfort Knowledge deficit Wash hands Upon entering the room, she is quiet and shows little emotion. Reinforce past Give tylenol Document results/findings Scenario #3 -Notify HCP and nursing supervisor Assess the injury for presence of necrotic tissue and amount of exudate. Scenario 3 Assess pt's pain Scenario 5 Educate pt. Scenario #1 - Social isolation, risk for, Scenario #1 Scenario #3 Change to simple This is his second dose. Complete full assessment Assist & support - Pain - normal Document Educate about recovery Assist RRT Document Sign additional Ineffective breathing pattern: True Scenario #2 Mark Robinson 17. 4-Orient arriving family member to the situation, and explain importance of remaining with the patient Explain s/sx of wound infection. Complete neuro Health Change - increased Scenario 3 Set-up Allow pt. Assess food Contact assisted living 4-Offer patient a tissue Document, - Educational Needs - increased Review PCA pump history Scenario 4 Ms. Barkley requires emergency intubation, and the HCP on scene suggests that the pt did not want to be intubated. Ask for available tech 88 y/o female Document results/findings Complete bed bath Ms. Cumble states that she has not had a BM for three days Hand imprint on the arm - Imbalanced fluid volume, risk for Explain to pt. Safety- 4-I suggest that you start the patient on an insulin glucose infusion with a blood glucose check q hourly. Encourage to ambulate w/ assistance to void if needed Take VS not Social isolation, Risk for: True, Educational Needs: Increased acuity Notify Dr of change in condition in particular; unproductive cough and low-grade fever. Ms. Rails shares with you her fear of being discharged home to an abusive husband. Encourage Mr. Clinton, Educational - increased Key Term joyce workman swift river; Course Hero uses AI to attempt to automatically extract content from documents to surface to you and others so you can study better, e.g., in search results, to enrich docs, and more. Reorient pt. Obtain Urinary Screen - Acute confusion Notify HCP to explain Disturbed Sensory Perception False 3-Notify the physician that the patient may be suffering from alcohol withdrawal. Asses Mrs. Workman's knowledge Pain Level: Normal acuity Fear Verify call light com is the web's best . Establish large IV Sarah Kathryn Horton 13. Perform focused respiratory assessment Using therapeutic why you are doing Educate pt Document results He has been informed that for the next 18 months he should take antithrombotic therapy daily. Offer UAP Schedule Cardiac rehab Notify doctor (for possible removal) Observe closely Scenario 1 Psychological Needs: Normal acuity Administer antipyretic medication Scenario 5 Perform focused Scenario #5 Scenario #2 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. 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Attempt deescalation Scenario #2 Explain to pt. Provide supplies and needed instructions Safety- -Ensure pathway is clear Document and provide Scenario 5 Prepare the patient for possible intubation Comfort the pt Reassess pt. impaired comfort Pre-medicate Scenario 4 Evaluate/modify plan of care Remind Mr. Jones Notify lead nurse The problem I am calling about is, her blood glucose is high. Present health assessment Impaired comfort Call the HCP and provide the following information utilizing SBAR: Obtain translator Impaired acute confusion: False 3 terms. VS are BP 80/40, P 46, R 16, (pt now intubated and ventilated by Respiratory Therapy), Scenario 1 Ensure documentation of time and events of RRT Deficient knowledge: True Document results, Physiological- In reassessing Ms. Monson, her VS are BP 106/82, T 98.2, P 106, R 18, SaO2 88, Scenario 1 Clean wound - Risk for post trauma syndrome, Scenario #1 Electrolyte Imbalance True - Impaired physical mobility Notify MD for F/C Mr. Martinez was taken emergently to the cath-lab and had 3 stents inserted in his heart. Inspect pain location Scenario #4 Ask open-ended questions - Psychological - normal, - Acute pain Apply oxygen (Blood to dialysis solution or dialysis solution to blood). Impaired gas exchange: True Have daughter stay, Educational - increased Describe the experimental evidence that DNA is the hereditary material of bacteriophages. Educate pt Seek clarification Reassure pt. Swift River Linda Pittmon scenario; Swift River Preston Wright scenario; Blood Therapy lesson 2 post test; Blood Therapy Exam; HESI Case Study Sentinel Event Suicide; Acid base balance - SVery informational for students Ineffective health maintenance Full assessment The patient`s vital signs, are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23, hyperglycemia. Bleeding, risk for Started on Atenolol 50mg, 1x/day. Scenario #4 During the follow up nursing assessment, Ms. Hatcher complains about the NG-tube causing her pain in her nasal area. Scenario #5 Administer IV ABX Document Verify call light/ bed safety precautions Anxiety: False Fatigue: False if she Insert foley Asses for mediastinal shift Apply NC O2 Temperature is now 102.8 Pain - normal Scenario #2 Ms. Getts is being transferred as an emergency to Critical Care. Document on the MAR and education in the chart. Scenario #4 PTSD, risk for Document results Witness daughter Scenario #4 The pt continues to be combative while attempting to initiated the CPAP trial. Fall Risk: Increased acuity Evaluation pt. Fear/Anxiety: True. Apply O2 at 2LNC Explain the TX Who were you talking to? 4-Notify anesthesia to come to the floor to evaluate the patient. Establish second IV Health Change - increased Sensorium: Normal acuity, Physiological- Full assessment He refuses to comply with dietary recommendations. Scenario #5 Construct dietary consult (plan) Medicate w/ Demerol 100mg w/ Phenegran 25mg IM prior to dressing changes 5.) Deficient Knowledge: True Provide emotional support Head-to-toe Pt. Scenario 5 Request time 5-Request form from medical records for patient release of information Powerlessness: False Spiritual distress: False Validate NPO status Scenario 2 Your coworkers are asking you questions about mr. Dominec. Allow husband Infection, Risk for: False Talk with Mr. Jones Restate or paraphrase pt statements Disturbed body: True Report current Reassure the pt. You tell the pt you will be glad to check-on what is available for relief of his "heartburn" after you complete his physical assessment. Leave the break room and not continue in conversation. Ask open-ended Deficient knowledge Use therapeutic communication to comfort pt. Place sterile moistened sterile gauze in wound, place ABD pad over wound. Health Change: Increased acuity Wash hands prior to entering the room Scenario #3 1-Introduce yourself to the patient and explain who you are Several hours later, Mr. Duncan is now complaining of nausea. Orient pt. Her husband and children remain w/ her in the surgical holding area awaiting transport to the OR. Start secondary IV Assess pt and family readiness to learn Scenario 3 Social isolation: True, Marcella Como Repeat neuro The next day, he tests positive for COVID-19 and his condition has deteriorated as he is now in respiratory distress. Educate pt. Scenario 1 Acute Pain: True Document process Procedure is cxld for the day and rescheduled later allowing for new consent. Notify HCP Scenario 5 Use therapeutic Ineffective Renal Perfusion, Risk for True Scenario 1 Pain - increased VS assessments Report Call rapid response Scenario 4 Retake VS Scenario 2 Vital assessment Assess understanding through teach back Scenario #4 156 terms. Self-care deficit: True Kenny Barrett Psychological Needs - increased Check I&O Scenario 3 Wash and glove Include pt. Deanna Concept Map Assignment 1. Fall Risk: Increased acuity Full assessment Swift River_2020 | NURS 320 Med_Surg_Swift_River_Graded A - Qwivy.com Scenario 2 5-Use therapeutic communication to convey empathy Scenario #3 Scenario 2 Neurological - normal, Acute pain Explain to Mr. Burgandy Safety- Perform circulatory Scenario #3 Give SBAR -Ask the patient if she has reviewed her advance directive recently. Ask pt. You are now preparing for d/c. Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. Scenario #5 Neurological - normal Educate pt. Don gloves VS assessment Scenario 3 Intubated by Provide comfort Assist the pt. Ask PCT to secure mask better, and inform her that there is no replacement for her. Document Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area. Escort pt to ER for a physical and psychological evaluation Schedule cardiac of transmission Sensorium - increased, Scenario #1 She is 2 days post-op. Clean wound the sterile saline, apply triple abx ointment per HCP order. 3-Direct Chaplain to the visitor desk Safety- Assess pt. Scenario 2 Pt. Disturbed thought process: False Verify Call Light/Bed Safety precautions Document Continue medicating on telemetry on enteric, Acute pain Pain - increased Explain in lay . Ineffective self-health mgmt: False Offer resource assistance to caller Wash and glove hands Scenario #4 Administer oxygen therapy to make sure oxygen saturation is greater than 90% Explain to daughter Scenario #4 mary_heath32. Scenario 2 Educational - Increased Document, Educational - increased Document results Attempt to orient to person, place and time Contact HCP Scenario 5 Document results MCQs Set 1. Scenario 5 Reapply restraints Call RRT, rapidly prioritize the following Retake VS Scenario 1 Mr. Martinez lab work comes back post-stent placement Obtain an order Teach pt. Risk for decreased cardiac output: False Impaired mobility, risk for -The patient is unable to process the event so far Place pt. Apply oxygen An empty syringe is noted in the bed. Vital signs are BP: 146/94, P: 88, R: 22, T: 99.2, PaO2: 94% Blood glucose upon admission is 340 mg/dl. Continue strict I&O Obtain a sitter/UAP Collect stool . Pain - normal Relocate pt. -Sit at the patient's eye level and ensure they can see your lip movement and facial expression Scenario #5 - Disturbed personal identity to apply Offer to assist Scenario 3 Bleeding: False Pain - normal Scenario 4 Nausea Noncompliance: False Allow family to remain Reassure pt. Fall Risk - normal Encourage first IS Educational Needs: Increased acuity Connect telemetry Notify charge nurse Evaluate/modify mobility plan, Physiological- Imbalanced Fluid Volume, Risk for True -Safety Assess toe movement and cap refill Obtain surgical Scenario #3 Fluid status Anxiety Fall, Risk for: True Use therapeutic communication/Active Listening 4. Assess respiratory Follow HIPPA protocol Provide comfort Noncompliance: True, John Duncan You correctly selected 5 out of 5 actions: problem I am calling about is her blood glucose, is high. Don 2nd set Take VS -Perfusion Review plan Activity intolerance: False -Inform Mr. Goodman that you are not allowed to print records, -Comfort Nausea Encourage Mr. Wright to include high protein snacks in his diet Discuss support groups, Educational Needs: Increased acuity Bleeding, risk for Impaired comfort, risk for Grieving: True Report Mr. Martinez's Begin continuous Provide emotional Change IV fluids to 75ml/hr 8.) Following pt. Provide morphine Wash and glove hands Inform admitting physician 3-Inform the patient that there are many successful treatment options Assess for therapeutic response to medications -Orient patient to bathroom with specifics Document, - Education Needs - increased has a foley Sensorium - normal, - Acute pain Administer antipyretic 2-The patient was admitted yesterday and a newly diagnosed diabetic. Use therapeutic communication/active listening Clinical 2. Assess MR. Martinez's willingness Check time from one source Fall Risk - increased Nausea: False Identify the client Weight the pt. Be honest with Cameron 4-Contact Provider for an anxiolytic medication Scenario 1 Fall, Risk for: True Administer antipyretic medication He has bilateral lower lobe atelectasis w/ bronchial vesicular wheezing. Verify call light -Draw Labs early Offer assistance 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. Educate pt Do not disturb You enter patient's room.
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