Med-Surg SR Exam Study Guide with Complete Solutions 2024
Tim 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 1 / 4
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 2 / 4
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 3 / 4
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
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