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Michael McDonald Clinical Assignment Nov 6th-12th.

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11/14/11 Michael McDonald

1. The nurse is teaching a female patient with multiple sclerosis. When teaching the patient how to reduce fatigue, the nurse should tell her to:
a. take a hot bath.
b. rest in an air-conditioned room (correct answer)
c. increase the dose of muscle relaxants.
d. avoid naps during the day

2. A patient is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client’s plan of care?
a. Disturbed sensory perception (visual)
b. Self-care deficient: Dressing/grooming
c. Impaired verbal communication
d. Risk for injury (correct answer)

3. For the patient with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:
a. prevent respiratory alkalosis.
b. lower arterial pH.
c. promote carbon dioxide elimination. (correct answer)
d. maintain partial pressure of arterial oxygen (PaO2) below 80 mm Hg

4. The nurse is positioning a patient with increased intracranial pressure.  Which of the following positions would the nurse avoid?
a. Head mid line
b. Head turned to the side (correct answer)
c. Neck in neutral position
d. Head of bed elevated 30 to 45 degrees

5. A patient has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:
a. Is clear and tests negative for glucose
b. Is bloody in appearance and has a pH of 6
c. Clumps together on the dressing and has a pH of 7
d. Separates into concentric rings on dressing and tests positive for glucose. (Correct answer.)

Patient was 6 days post op for a Gastrectomy, due to cancer occluding his pyloric sphincter. He was in a state of delirium when I had him as a patient, which according to the H&P and nurses report was a change over the last few days. He had a J-tube in place and was receiving continuous feeding through it, and a JP drain (with a scant amount or sanguinous fluid.) He was receiving Zyprexa IM for his agitation. He was oriented to person, but not place, time, or situation. He had a morphine PCA (no basilar rate) and couldn't understand to press the button. He was No Code Blue status.

6 nursing Interventions related to perfusion/cellular regulation.
-I. Maintain continuous pulse oximetery
-R. The Pulse ox will give a real time quantifiable number relating to how well the extremity being monitored is perfused.
-I. Have patient cough and deep breathe
-R. Coughing and deep breathing will clear secretions out of the lungs allowing for more gas exchange to take place.
-I. Maintain supplemental oxygen as ordered.
-R. Supplemental oxygen will help make shallower breaths more efficient, up to a point.

-Cellular Regulation
-I. Routinely assess for pain, treat as necessary and ordered.
-R. Cancer can be extremely painful, as can surgery. Pain control aids in recovery.
-I Assess for fatigue, promote restful sleep.
-R. Cancer is metabolically demanding, and fatigue is common. Promoting restful sleep will maximize the therapeutic effects of sleep and leave more energy for awake periods.
-I. Ensure that continuous feeding tube is patent and delivering nutritionally dense products, as ordered.
-R. Promoting energy for the healing process.

A patient with an INR of 4, would be on a Coumadin (warfarin sodium) regimen. This level is high, even for cardiac valve replacement. This patient would probably be taken off of the Coumadin, and given Vitamin K, which reverses the effects of Coumadin (in roughly 12-24 hours.)

-I. Assess Vital Signs.
-R. Changes in the vital signs could indicate hemorrhaging.
-I. Review Laboratory data. Especially H/H and PT/INR
-R. Changes in the daily labs could indicate hemorrhage.
-I. Protect patient from falls, or other accidents.
-R. Avoid damaging injuries that could result in internal or external bleeding. It would be difficult to stop the bleeding.


That must have been difficult seeing that patient in pain without the understanding to operate his PCA pump. Wonder what could be done to help the patient in that situation?


He was scheduled to consult with Hospice later that afternoon.

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