Reference no: EM133249746
1. For each of the problems listed provide:
One goal, 4 interventions and 4 rationales, and one way to evaluate if your care has been effective care.
A. Pain
B. Constipation
C. Altered nutrition: Less than body requirements R/T decreased appetite 20 to depression: Nutritional Counselling
D. Altered nutrition: Less than body requirements R/T decreased appetite 20 to depression: Nutritional Monitoring
E. Altered nutrition: Less than body requirements R/T decreased appetite 20 to depression: Nutritional Management
F. Fluid Balance Deficit
G. Decreased mobility: skin surveillance
H. Sleep pattern disturbance related to psychological stress from job pressures: Sleep enhancement
2. Identify and explain one test you could complete on a patient to assess their:
a. Immediate memory
b. Recent memory
c. Remote memory
3. The patients' care plan identifies ongoing Glascow Coma Scale assessment. How does the nurse complete the following in relation to completing a GCS?
a. Check
b. Observe
c. Stimulate
d. Rate
4. Your patient's pupils are recorded as PERRLA in the patient notes. What does this mean? Explain each letter of the acronym
1. Name two tests to assess a patients:
a. Reflex's
b. Sensory function
c. Motor function
5. Your patient is needed a liquid medication. How do you measure a liquid medication in relation to the meniscus?
6. Your patient has been ordered the following medications:
1. Paracetamol.
2. Docusate and Senna
Explain the following:
a. 2 counselling notes that you will share with your patient
b. 2 practice points that you need to be aware of as a nurse
7. Your buddy nurse asks you to explain the difference between primary and secondary intention.
8. Identify 4 questions you would ask your patient when completing a wound history.
9. List two intrinsic and two extrinsic factors that inhibit wound healing
10. Explain how you would describe the following attributes of a wound
a. Depth of loss of tissue
b. Clinical appearance
c. Exudate
d. Peri-wound
e. Wound measurement
11. Your patient is complaining of urgency and frequency on voiding. Identify 4 areas of question you would explore for this patient no related to pain.
12. You need to complete an abdominal assessment on you patient. Explain what you would be looking for in relation to
a. Inspection
b. Auscultation
c. Palpation
13. Your buddy nurse asks you to explain in what circumstances would you expect to see the following results when completing a dipstick:
a. Bilirubin
b. Blood
c. Glucose
d. Ketones
e. Leucocytes
f. Protein
13. What is the normal SG and pH of urine?
14. You are caring for a patient with a urinary catheter insitu. Prior to administering care your buddy nurse asks you the following questions
a. Identify 4 indications for the insertion of a urinary catheter?
b. What are 3 complications associated with catheterisation?
c. List 6 signs/symptoms of UTI's
d. List 4 risk factors for urinary incontinence
e. How many bladder measurements should you do when performing a bladder scan?
f. You have a patient who is being discharged with a catheter. What discharge planning would you perform to ensure a safe discharge?
15. The patient you are caring for has just been diagnosed with Diabetes Mellitus. You are taken a BGL 3 times a day 30 minutes prior to each mealtime. They ask you the following questions;
a. What 5 symptoms of hypoglycaemia?
b. What are two reasons for wiping the patients' hand with a warm cloth?
c. Why do you rotate the sites when taking a BGL?
d. What are two strategies they can use to encourage blood flow to the area prior to taking a BGL?
e. What part of the finger should they take the blood from? Why?
16. State 4 indications for intravenous infusion therapy.
17. What are 5 potential sources of infection for someone with an intravenous canula (IVC)?
18. Identify 3 risk management strategies a nurse implements to reduce the risk of infection for a patient with an IVC?
19. Your buddy nurse asks you to explain how you will' look, listen and feel' when caring for a patient with an IVC.
20. Explain the three types of Phlebitis:
a. Mechanical
b. Chemical
c. Infectious
21. Your patient has charted passive range of movements. Explain the difference between active and passive range of movements.
22. Explain how the respiratory system is impacted in a patient with reduced mobility.
23. Explain how the musculoskeletal system is impacted in a patient with reduced mobility.
24. Explain the 2 aspects that a nurse is assessing when completing a neurovascular assessment.
25. List 4 indications for taking a set of neurovascular observations (NVO's)on a patient.
26. What are two conditions/local factors that may affect a patient's neurovascular status.
27. When completing a set of NVO's you need to assess pain, circulation, sensation and motor function. Explain how you would assess the following:
a. Motor function of the upper limb?
b. Motor function of the lower limb?
c. Movement of the upper limb?
d. Movement of the lower limb?
28. There are 3 main principle to consider prior to engaging a patient in education. Explain them:
a. Motivation to learn
b. Ability to learn
c. Learning environment
29. Your patient needs a set of NVO's. Upon entering the room, you note that they are asleep. What is the best course of action in this circumstance - should you let them sleep or wake them up to complete the observations? Explain your reasoning.
30. Your patient needs some to be taught incentive spirometry. Explain how you will teach your patient to complete incentive spirometry.
31. Your patient needs some to be taught how to complete deep breathing exercises. Explain how you will teach your patient to complete deep breathing exercises.
32. Explain why a patient may prefer nasal prongs as compared to a Hudson mask.
33. A patient requires a non-rebreather mask. Outline three important steps you need to complete in order for the mask to work correctly.
34. In relation to end of life care explain the following:
a. Why is it important to include pain relief?
b. What is the goal of end of life care?
c. List 4 critical elements of end of life care.
35. A patient in your care requires a focussed sleep assessment. List possible questions you will ask to obtain a satisfactory assessment of their current sleep patterns.
a. Nature of the problem:
b. Signs and symptoms:
c. Onset and duration:
d. Quality of sleep:
e. Predisposing factors:
f. Effect on client: