PTP Coding Edits
Pruritus, urinary retention, and vomiting may occur but are not life threatening. Option 3 addresses pain. Determining attainment of client goals occurs as part of evaluation. I could hear myself in my ear when I spoke. An action plan should be developed. Ambulating the patient after administering medication. You are caring for a post-operative cholecystectomy client.
Test Your Knowledge
Draw a single line through the diagnosis on the care plan and write the nurse's initials and date Rationale: The other options are not relevant to the question as presented. Elbow extension with shaving and eating. You notice that the patient has reddened blotches on the face and arms. Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse.
Shame on you, really. Don't talk to me. I'm guessing they'll say Menniers again as it seems the easy option! Other consultants have disagreed! Mine has been continuous now for a year! Hi Carmen, can you give me a very detailed account of your symptoms, any tests you have had - particularly hearing test, tympanometry and speech discrimination.
Do you have an asymmetry in hearing or speech discrimination? Have you had an MRI? Does anything relieve your symptoms? Based on my research, ear fullness also called Aural Fulliness is a common symptom of many vestibular disorders. Have you had vertigo room spinning attacks lasting longer than a couple of minutes? This is common symptom of Meniere's disease. Yes I've had vertigo that's lasted hours but "one off's" and I've had Two which were Twelve months appart.
My consultant diagnosed migraine with vertigo as there is a family history. He dismissed menniers because of my age. I'm 61 and was told you can't develop menniers after the age of I've had a MRI scan which came back normal and have seen a neurologist who "suspects" migraine but not sure as I rarely get headaches or other common related symptoms.
I've had tinitus for Thirty years which has been quite mild however since the fullness in my left ear started last year it's much louder with a different tone alongside the one I already had. Also my hearing deteriorated in that ear. For Eight months the hearing loss and fullness was intermittent lasting a few days or weeks and my hearing returned to normal.
However since June last year it's been continously full again with hearing loss. The latest has been ive been given a hearing aid. Whilst this has had no positive affect on my fullness and tinitus it's obviously improved my hearing and the fullness isn't so apparent which has taken the focus off of it. So more comfortable and I don't feel so off balance.
My apointment with the consultant has now been pushed back till March so have to see what happens next! I visited an otology consultant yesterday. I was put through many tests ETF, tympanometry, audiogram,ecog.. Results said i have a partial ETD in my left ear, plus some other results which lead to a diagnosis of Menier's Disease. Ive clearly explained to the doctor that my dizziness is NOT vertigo.
He said regardless, menier's doesnt always have the typical triad of symptoms and that this could be simply called atypical Menier's. He put me on a diuretic, a steroid decongestant and an oral decongestant.
Could menier really come with my clinical picture? I am so glad you have got some answers. You can always take your results to a few other ENT's for second and third opinions.
I regularly see clients who have been diagnosed with Meniere's or atypical Meniere's. When they go and get other opinions they are often diagnosed differently. I think the main thing to do is to trust this ENT for now.
Try what he says and see if it helps. If he is correct, it should make some difference. I see clients that are diagnosed with Menieres that don't have the typical symptoms. Not sure if they are misdiagnosed or don't have the typical symptoms????
There are lots of grey areas which is shown by the varied opinions of some brilliant ENTs. Please let us know how the treatment goes. I hope you see changes quickly!! I understand your reservation about your diagnosis.
Getting a proper diagnosis for a vestibular condition can be a process. It can take going through several treatments and Drs. I tend to agree that your symptoms don't match well with Menier's since you don't have episodes and have fairly constant dizziness symptoms. It also doesn't seem to explain your sensitivity to noise. However, you probably need to follow the process and give the Drs advise a try. If it helps then great, if it doesn't I would still suggest pushing for the temporal bone CT scan.
I think SCDS is a much better fit of your symptoms. It is definately more rare. However, it can be tested for to rule it out or in. I suggest being patient but not giving up until you find a treatment that works or a conclusive diagnosis.
FYI, my understanding about Mienier's is that hearing loss develops over time and is more prominant long term. That way you will learn a bit more about why they do think it is Menieres. Im definitely going to take that CT, i did mention it to the doctor last time and he said he just wants to try and stick with the treatment he prescribed first and if things didnt get better he does have it in mind.
May i ask how your symptoms started and whats the main conplaint that had you visiting doctors in the first place? So far im doing bad actually, the treatment is simply not working.
I didnt mention he also put me through 2 chair trestment sessions, where they treat bppv as he said hes suspecting bppv too. I have chated with many people who have SCDS and found that symptoms vary quite a bit. For me, I had a mild dizziness that started from barely noticable. Eventually, this annoyed me enough that I asked my general Dr. He referred me to Neurologist and got an MRI, ruled out a few conditions. He requested some more tests, but I didn't follow up. Then a few years later, I woke up one morning with fullness in my ear and it felt like I had water stuck in my ear.
I could hear myself in my ear when I spoke. I made an appointment with an ENT a few days later when it didn't get any better. He did his thing and one test came back very strange. The tuning fork test. When placed anywhere on my head, I could hear it loudly in my affected ear. I was then sent for hearing test that came back totally normal. He explained that my symptoms might be caused by perilymph fistula.
Same day I got the scan he called me later with the findings. I went back for a confirmation test called a VEMP which showed an abnormal result in my affected ear. Then a few years later, could start to hear heartbeat, eye movements etc. I also developed the sensitivity to noise like plates, silverware, clapping for a year, but it has mostly gone away for the last few months glad to not be carrying around ear plugs anymore. I have hear of others that get all the symptoms at once but for me they developed gradually over time.
Some people can remember an event where the dehiscence is triggered and others not. Some people only have dizziness and others only autophony. This condition mimics many other vestibular conditions making it a difficult diagnosis especially when only some or minor symptoms are present. I was lucky in that my first ENT was able to make the diagnosis. Hi, sorry to bother you, I have been having some of the symptoms you describe for about 6 months now.
I am going to request a CT scan. May I ask what if any treatment you have had. The only good treatment for SCDS is surgery. So far, I have been trying to put this off. I am just trying to live with the symptoms for now. I am researching and looking into options and surgeons in case needed. Increasing pain, decreasing vision after phacoemulsification Mar 19, Weekly case challenge Diagnose This.
Eye fatigue and intermittently blurred vision at near Diagnose This Diagnose This: Trauma-induced bilateral superior oblique paresis Diagnose This Diagnose This: Idiopathic orbital inflammation Diagnose This. Technologies for Patients with Low Vision. Vitesse-Assisted Macular Hole Repair.
Caffeinated Beverages and Glaucoma: Is There a Link? Cataract Spotlight - Case 5 Ultrabrunescent Cataract. Client will be able to turn self by day 3 B. Skin will remain intact and without redness during hospital stay C. Client will state pain relieved within 30 minutes after medication D. Pressure will be prevented by repositioning client every 2 hours. Skin will remain intact and without redness during hospital stay Rationale: The label suggests the outcomes.
In this case, "skin will remain intact" is the desired outcome for a client at risk for impaired skin integrity. Option 1 addresses immobility. Option 3 addresses pain. Option 4 is an intervention. While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment? Help client into the chair but more quickly B.
Document client's vital signs taken just prior to moving the client C. Help client back to bed immediately D. Observe client's skin color and take another set of vital signs. Observe client's skin color and take another set of vital signs Rationale: Assessment is ongoing throughout the nurse-client relationship.
During re-assessment, the nurse collects additional data to help evaluate the status of problems or identify new problems. Options 1, 2, and 3 are interventions. After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods?
Achievement of 90 on written test D. Have client explain produce to the family. Interpersonal skills are the sum of the activities the nurse uses when communicating with others. Cognitive skills are the intellectual skills of analysis and problem-solving and are evaluated by tests.
The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult? Formulate a nursing diagnosis of impaired gas exchange B. Record in the medical record the distance a client ambulate in the hall C. Write individualized nursing orders in the care plan D. Compare client responses to the desired outcomes for pain relief. Record in the medical record the distance a client ambulate in the hall Rationale: The implementation phase of the nursing process involves carrying out or delegating the nursing interventions and recording nursing activities and client responses in the medical records.
Option 1 represents diagnosing. Option 3 represents planning. Option 4 represents evaluation. A client on the nursing unit is terminally ill but remains alert and oriented.
Three days after admission, the nurse observes signs of depression. The client states, "I'm tired of being sick. I wish I could end it all. Client appears to be depressed, possibly suicidal B. Client reports being tired of being ill and wants to die C. Client does not want to live any longer and is tired of being ill D.
Client states, "I'm tired of being sick. Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse.
This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal. The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved.
How should the nurse document this so that it is best communicated to the healthcare team? Recopy the care plan without the resolve diagnosis C.
Write a nursing process not indicating that the outcome goals have been achieved D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date.
Some agency forms may require the nurse to put date and initials in a "Date Resolved" column. Using Liquid PaperTM is not a legal way to amend client records. Outcome goals that have been met and nursing diagnoses that have been resolved should be documented on the care plan. A progress note should also be written, but a single note may not be read by all health team members. The client is being discharged to a long-term care LTC facility.
The nurse is preparing a progress note to communicate to the LTC staff the client's outcome goals that were met and those that were not. To do this effectively, the nurse should: Formulate post-discharge nursing diagnoses B. Draw conclusion about resolution of current client problems C.
Assess the client for baseline data to be used at the LTC facility D. Plan the care that is needed in the LTC facility. Draw conclusion about resolution of current client problems Rationale: Terminal evaluation is done to determine the client's condition at the time of discharge. This evaluation is best reflected in option 2 because it focuses on which goals were achieved and which were not. Ongoing evaluation is done while or immediately after implementing a nursing intervention.
Intermittent evaluation is performed at specified intervals, such as twice a week. Items related to care post-discharge options 2, 3, and 4 should be done on admission to the LTC facility. A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?
Help the client to get settled and do the interview the next morning when the client is rested B. Do the interview immediately, directing the majority of the questions to the client's spouse C. Do the interview as soon as some uninterrupted time is available in order to address the client's concerns D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication.
Do the interview as soon as some uninterrupted time is available in order to address the client's concerns Rationale: To collect data accurately, the client must participate.
Attending to the client's immediate personal needs before expecting the client to focus on the interview will maximize the accuracy of the data collected. Data should be collected shortly after admission. The best source of data is the client. The management of the client's anxiety is the responsibility of the nurse conducting the interview and initiating the relationship.
The nurse overhears an unlicensed assistive person UAP who has just been accepted to nursing school say to a client, "You must be so pleased with your progress. A leading question is asked in a way that suggests the type of answer that is expected. This can result in inaccurate data collection. A closed-ended question generally requires only a "yes" or "no" or short factual answer. Open-ended questions encourage clients to elaborate on their thoughts and feelings.
Neutral questions do not influence the client's answer. The nurse would do which of the following activities during the diagnosing phase of the nursing process? Collect and organize client information B. Identify problems, risk, and client strengths D. Develop nursing diagnoses E. Develop nursing diagnoses Rationale: The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses.
Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase. The functional health pattern assessment data states: Client has an actual health problem B.
Client has a wellness diagnosis C. Collaborative health problem needs to be written D. Possible nursing diagnosis exists E. Specific questions about the diet should be asked next.
Client has a wellness diagnosis E. Specific questions about the diet should be asked next Rationale: The description indicates a healthy pattern of nutrition for the client. A wellness diagnosis might be stated as: The nurse should also do a diet assessment to determine the quality of the food eaten during meals. These actions by the nurse are within the scope of independent nursing practice and are not collaborative in nature.
For the nursing diagnostic statement, Self-care deficit: The etiology or related factors of a nursing diagnostic statement define one or more probable causes of the problem and allow the nurse to individualize the client's care. In this case, the fracture is the cause of the client's feeding problem. The nurse would make which of the following inferences after performing the appropriate client assessment?
Client is hypotensive B. Respiratory rate of 20 breaths per minute C. Client relays anxiety about blood work. Client is hypotensive Rationale: An inference is the nurse's judgment or interpretation of cues such as judging a blood pressure to be lower than normal. A cue is any piece of data information that influences a decision. Options 2, 3, and 4 are cues that could lead to inferences. The nurse would write which of the following outcome statements for a client starting an exercise program?
Client will walk quickly three times a day B. Client will be able to walk a mile C. Client will have no alteration in breathing during the walk D.
Client will progress to walking a minute mile in one month. Client will progress to walking a minute mile in one month Rationale: Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. They should also be realistic and achievable. The nurse decides it would be beneficial to the client to allow the client's infant granddaughter to visit before the client's scheduled heart transplant.
Before implementing this intervention the nurse should collaborate with which of the following? Client and Family B. Other nursing staff on the unit C.
This is not a collaborative intervention so no collaboration will be needed prior to implementation. Other nursing staff on the unit Rationale: Collaboration with the client and family will encourage a sense of autonomy and active involvement in the healthcare process for the client. In this case collaboration with other nursing staff will ensure the successful implementation of the planned intervention. There is no real need for collaboration with hospital administration or the security department in this situation although the nurse should be aware of her responsibility to collaborate at those levels when the situation demands it.
The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time? The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process.
Data gathering occurs during assessment. Goal setting occurs during planning. Determining attainment of client goals occurs as part of evaluation. A desired outcome for a client immobilized in a long leg cast reads; Client will state three signs of impaired circulation prior to discharge.
When the nurse evaluates the client's progress, the client is able to state that numbness and tingling are signs of impaired circulation. What would be an appropriate evaluation statement for the nurse to write? Client understands the signs of impaired circulation B. Client cited numbness and tingling as sign of impaired circulation C. Client able to name only two signs of impaired circulation D.
Client unable to describe signs of impaired circulation. Client able to name only two signs of impaired circulation Rationale: The goal has not been met because the client states only two out of three signs of impaired circulation.
By comparing the data with the expected outcomes, the nurse judges that while there has been progress toward the goal, it has not been completely met. The care plan may need to be revised or more effective teaching strategies may need to be implemented to achieve the goal. A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire? In the event of a fire, the nurse's priority responsibility is to rescue or protect the clients under his or her care.
The next priorities are to report or alert the fire department, contain or confine, and extinguish the fire. A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority? Drowning and firearms 3. When educating a group of young to middle-aged adults on safety, it is important to instruct them on the leading cause of injuries in this group. The leading cause of injuries in this group is related to automobile use.
Option 2 is the leading cause for school-age children. Option 3 is the leading cause for older adults, and option 4 relates to adolescents. When planning to teach health care topics to a group of male adolescents, which topic should the nurse consider a priority?
Sports contribute to an adolescent's self-esteem. Sunbathing and tanning beds can be dangerous. Guns are the most frequently used weapon for adolescent suicide. A driver's education course is mandatory for safety. Suicide and homicide are two leading causes of death among teenagers.
Adolescent males commit suicide at a higher rate than adolescent females. Options 1 and 2 are true; however, neither would be as high a priority as preventing suicide. Option 4 is not true. A driver's education course does not ensure safe practice.
Isotonic exercises such as walking are intended to achieve which of the following? Increase muscle tone and improve circulation. Increase muscle mass and strength. Decrease heart rate and cardiac output. Maintain joint range of motion. Isotonic exercise increases muscle tone, mass, and strength, maintains joint flexibility, and improves circulation. During isotonic exercise, both heart rate and cardiac output quicken to increase blood flow to all parts of the body option 4.
Little or no change in blood pressure occurs option 2. Five minutes after the client's first postoperative exercise, the client's vital signs have not yet returned to baseline.
Which is an appropriate nursing diagnosis? Risk for Activity Intolerance. Risk for Disuse Syndrome. Vital signs that do not return to baseline 5 minutes after exercising indicate intolerance of exercise at that time. This is a real problem, not "at risk for," as in option 2. There is no evidence that the client requires assistance impaired mobility, option 3 , or is immobile disuse syndrome, option 4.
Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching? Although the crutches or cane are always used along with the weaker leg, the weaker leg should go down the stairs first.
The stronger leg can support the body as the weaker leg moves forward. All of the other statements are correct. A nurse is teaching a client about active range-of-motion ROM exercises. The nurse then watches the client demonstrate these principles. The nurse would evaluate that teaching was successful when the client does which of the following?
Exercises past the point of resistance. Performs each exercise one time. Performs each series of exercises once a day. Uses the same sequence during each exercise session.
When the client performs the movements systematically, using the same sequence during each session, the nurse can evaluate that the teaching was understood and is successful. When performing active ROM the client should exercise to the point of slight resistance, but never past that point of resistance in order to prevent further injury option 1.
The client should perform each exercise at least three times, not just once option 2. The client should perform each series of exercises twice daily, not just once per day option 3. When assessing a client's gait, which does the nurse look for and encourage?
The spine rotates, initiating locomotion. Gaze is slightly downward. Toes strike the ground before the heel. Arm on the same side as the swing-through foot moves forward at the same time. Normal gait involves a level gaze, an initial rotation beginning in the spine, heel strike with follow-through to the toes, and opposite arm and leg swinging forward. Performance of activities of daily living ADLs and active range of motion ROM exercises can be accomplished simultaneously as illustrated by which of the following?
Elbow flexion with eating and bathing. Elbow extension with shaving and eating. Wrist hyperextension with writing. Thumb ROM with eating and writing. Hip flexion with walking.
Eating and bathing will flex the elbow joint, and grasping and manipulating utensils to eat and write will take the thumb through its normal ROM. Walking flexes the hip. Shaving and eating require elbow flexion, not extension option 2. Writing brings the fingers toward the inner aspect of the forearm, thus flexing the wrist joint option 3.
He is laughing, watching football, and is in conversation with a visitor. Based on the assessment, what intervention should the nurse employ? Give the total dose of pain medication Pain is a multidimensional phenomenon that is difficult to define. It is personal and subjective and is whatever the patient says it is. Three days after undergoing exploratory laparotomy and lysis of adhesions, a patient tells the nurse that his pain is no better than on the first day postop and he fears that he will be unable to return to his work withing the allotted time frame.
Which response by the nurse is the most appropriate for the situation? As your body heals, your pain should resolve" Acute pain occurs after surgury and is usually limited and of predictable duration. Increased activity is needed to maintain function, promote healing, and prevent complications of surgery. At 7 months after back injury and lumbar laminectomy, a patient complains of tenderness at the operative site and appearss depressed and unwell.
Other symptoms include depression, fatigue, and sleep disturbances. Which nursing diagnosis is a priority for this patient? Chronic Pain Chronic pain has vague symptoms and few other physical findings and occurs beyond.
A 28 year old quadriplegic complains of burning pain in his lower legs. What type of pain should the nurse suspect? A 72 year old patient is hospitalized after a fall at home, is restless, has elevated blood pressure, and moans with turns. When the nurse asks, the patient denies being in pain. What initial interventions should the nurse employ? Discuss the symptoms and explain how medication will increase comfort and increase healing Older adults are hesitant to express pain becasue they may fear being labeled as a complainer.
When caring for a patient with a suspected viral infection, which medication order would the nurse question? Aspirin ASA may pose a risk for people of any age when administered to those with viral infections. Adults have experienced Reye's syndrome-like manifestations. While reviewing the medication list for an older client with a history of heart failure, diabetes, and hypertension, which medication might cause concern?
Dolobid mg Salicylate salts containing mg or na should be avoided in clients whom excessive amounts of these electrolytes might be harmful. An 80 year old patient who is recovering from a hip fracture with surgical nailing is becoming increasingly confused and unable to participate in care, and has experienced several periods of urinary incontinence.
Which orders might the nurse suspect of contributing to the patient's sypmptoms? Meperidine 25mg Meperidine causes confusion and delerium in the older adult and should be used caustiously in patients with altered renal function. When admitting a postop patient to the surgical unit, which nursing action is a priority? Conduct Pain Assessment Assessment is a constant ongoing task for the postop patient.
What is a realistic outcome for the patient who is terminally ill with bone cancer and is experiencing uncontrolled pain? The patient experiences improved quality of life. The patiens wife voices her concern that the patient is becoming addicted to the medication and questions whether milder nonnarcotic medications could be used. What is the most appropriate response by the nurse? With the diagnosis of cancer, there is a need to use regular and strong mediaction for pain control to provide a better quality of life Persistent pain can be managed using long acting medications and narcotics when the condition warrants their use.
Addiction is not an issue for the patien with chronic cancer pain. Amount and types of meds are adjusted according to patient status. Which order would the nurse question when caring for a postop patient receiving epidural morphine infusion? When assessing chronic pain in the older adult, which question will be most helpful in determining appropriate interventions?
Two days after undergoing surgery, a patient refuses to get out of bed. What information can the nurse provide that may increase compliance with the treatment plan? Movement can cause breakthrough pain. We can give you medication to control the pain and help you to increase your activity.
A non-english speaking hispanic client is moaning and appears to be in pain. How does the nurse intervene to faciliatate adequate pain management? If an interpreter is available, explain that pain is related to illness and by treating the pain healing will promote wellness Moaning and crying are used to alleviate the pain rather than communicate a need for intervention. If the patient understands that pain is related to illness there is a higher likelihood that the patient will accept treatment.
Which factor regarding older adults and medication is important for the nurse to understand? The older adult is more likely to experience drug interactions than the general public.
What information about pain must the nurse understand when designing a plan of care to manage pain? Past experience with pain effects the way current pain is perceived Past experience affects the way current pain is perceived, the impact of pain experiences is not predictable, anxiety influences an individuals response to pain, and no matter what the experience is, one never becomes accustomed to pain.
A terminally ill patient is experiencing chronic pain due to spinal cord tumor and has been admitted on several occasions for pain crises. Which intervention can produce positive outcome for the individual with uncontrolled pain and a short life expectancy?
Analgesic Nerve Blocks Analgesic blocks using neurolytic agents block nerve conductivity and destroys the nerves. Topical anesthesia, local anesthetic agents, and nonnarcotics are not effective for a patient experiencing pain due to cord compression. A patient with cancer is experiencing increased pain issues. A plan is developed for adding ibuprofen mg BID to the medication regimen of narcotics. The patient asks the nurse why he is now expected to take ibuprofen because he does not have arthritis.
What is the most appropriate reply by the nurse? Narcotic doses may still need to be increased as the disease is progressive. NSAIDS have an anti-inflammatory effect, but the ability to block prostaglandin synthesis promotes their pain-relieving properties. There is no information to support that they act more slowly or extend pain relief. You are caring for a 72 year old patient with advanced cancer who complains of increased pain and tactile sensitivity over the last several weeks.
Which non pharmacological alternative could be added to her plan of care to enhance her comfort? Therapeutic Touch Therapeutic touch is thought to realign aberrant energy fields through passing hands over the energy fields without actually touching the body and promoting comfort. It is most important for the nurse to understand the various ways in which pain is classified. So that he can educate the client thoroughly. The nurse is assessing the confused client, in trying to determine the client's level of pain, the nurse should: Observe the client carefully for changes in behavior or vital signs Rationale: Xenobia's chronic cancer pain has recently increased and he asks the home health nurse what can be done.
In relationship to his long-acting morphine, which of the following is an appropriate response by the nurse? B "I'll call the physician and ask for an increased dose" Rationale: Patients develop a tolerance to the effects, which often necessitates an increase in the dose. Farrell have both had their gallbladders removed laparascopically. Mitchell is rating his pain at a 5 on a pain scale and states he does not require pain medication.
Farrell is rating his pain a 5 on a pain scale and is demanding something stronger for his pain. This is an example of a difference in which of the following? Surgeon's skill b Patient's pain thresholds c. Patient's pain tolerance Rationale: Both patients would perceive the surgical incision to be painful at about the same point. Mitchell is able to tolerate his pain when it is rated at a 5, whereas Mr.
The patient's personality is a factor that affects pain tolerance. When establishing a plan for pain control, what question would the nurse first ask the patient?
How does the presence of this pain affect your life? Before developing a plan for controlling a patient's pain, the nurse must elicit information about the patient's perception of his pain. The use of percutaneous electrical stimulation as an effective means to control pain is based on which of the following?
Concept of therapeutic touch c. A 73 year old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing? Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones.
Therefore, a hip fracture causes deep somatic pain. Phantom pain is a pain that is perceived to originate from a part that was removed during surgery. Visceral pain is caused by deep internal pain receptions and commonly occurs in the abdominal cavity, cranium, and thorax. Referred pain occurs in an area that is distant to the original site. Which pain management task can the nurse safely delegate to nursing assistive personnel?
The nurse can delegate the task of asking about pain when nursing assistive personnel obtain vital signs. The NAP must be instructed to report findings to the nurse without delay. The nurse should evaluate the effectiveness of pain medications and develop the plan of care. Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen Tylenol a. Occasional alcohol use c.
Which action should the nurse take before administering morphine 4. Assess the patient's incision b. Clarify the order with the prescriber c. Assess the patient's respiratory status. The nurse administers codeine sulfate 30mg orally to a patient who underwent craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain? Codeine administered by the oral route reaches peak concentration in 60 minutes; therefore the nurse should reassess the patient's pain 60 min after administering.
The nurse should reassess pain after 10 min when administering codeine by IM or SC routes. Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis a. Low dose aspirin therapy is commonly administered to decrease the risk of thrombophlebitis, MI, and stroke.
When does atelectasis usually occur after surgery? How do you prevent atelectasis?
Iamges: corticosteroid therapy patient teaching
Goal setting occurs during the planning phase.
Same day I got the scan he called me later with the findings. I hope you get an answer soon. A maxillary surgeon does xrays and usually over time your face kind of look square.
Before implementing this intervention the nurse should collaborate with which of the following? Clinical pathways and disease management cycle winstrol oral The nurse should corticosteroid therapy patient teaching do a diet assessment to determine the quality of the food eaten during meals. You are reviewing your client's understanding of the post-operative stapedectomy instructions that you gave several days ago. A client is admitted through the emergency department for a strangulated intestinal obstruction with perforation. I would love to hear everyones opinion, each and corticosteroid therapy patient teaching reply is highly appreciated. Options 1 and 2 are true; however, neither would be as high a priority as preventing suicide.