FA Davis Linda Watson, NURSING 432 Q,A

Erika Hightower Linda Watson Linda Watson | Interview the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. 1. Good afternoon, Ms. Watson. May I check your armband? My name is Pat and I am a Registered Nurse. Rationale Relevancy Your Answer Before any assessments or procedures, the nurse should knock on the door (if applicable) and introduce himself or herself, explain the purpose of the encounter, ensure patient privacy, wash hands, and don appropriate personal protective equipment (PPE). Relevant Relevant Patient: Yes, I suppose. 2. Can you tell me what has been happening lately? Rationale Relevancy Your Answer Encourages the client to express her feelings and identify her concerns. Relevant Relevant Patient: I have just been feeling so bad for so long. I feel as if my life will never get better. 3. Why would you decide to try to take your life? Rationale Relevancy Your Answer This question could be seen as judgmental by the client and would not be therapeutic or helpful. Irrelevant Irrelevant Patient: There were no other options for me. 4. Didn’t you think about what this would do to your family? Rationale Relevancy Your Answer This question could be seen as judgmental by the client and would not be therapeutic or helpful. Irrelevant Irrelevant Patient: They would be better off without me. 5. Tell me about one stressor that you have that seems overwhelming right now. Rationale Relevancy Your Answer Encourages the client to identify contributing factors. Relevant Relevant Patient: I was recently transferred to a new area at work. I just can’t seem to fit in. My coworkers and supervisor identify mistakes I have made daily. I feel like such a failure. If I lose my job I don’t know what I will do. 6. What made you decide to overdose with pills? Rationale Relevancy Your Answer This question might be seen as judgmental by the client and would not be therapeutic. Irrelevant Irrelevant Patient: I just decided I couldn’t deal with it anymore. 7. What have you used in the past to cope with stress? Rationale Relevancy Your Answer Determining previously used coping behaviors and the client’s perception of those behaviors will enable her to problem solve. Relevant Relevant Patient: I had supportive mentors and colleagues in the department that I was in. We problem solved together when an issue came up. 8. Who are your support people? Who do you talk with when your life seems overwhelming? Rationale Relevancy Your Answer Encouraging the client to identify support people in her life enables her to develop additional coping resources. Relevant Relevant Patient: Previous coworkers became friends and support people; however, we have lost touch and I haven’t talked to them lately. I used to be close to my sister-in-law, but when my marriage broke up several years ago, that became awkward. I have a brother and a niece here and a sister, but she moved to Europe 6 months ago. My daughter is away at university and I don’t like to bother her with my problems. 9. Have you accessed community resources? Rationale Relevancy Your Answer This question assesses the client’s knowledge and use of available community resources. Relevant Relevant Patient: I did see a counselor for several months when my marriage broke up and I attended a support group for people who were also going through separation and divorce. Copyright @2017 by FA Davis Linda Watson | Assess the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. • Psychosocial Assessment • Inspection • Palpation • Auscultation • Percussion It is important to maintain the client’s comfort level during the interview. When the client is in distress or is overly apprehensive or anxious, the examiner will want to make the exam as short as feasible while still gathering necessary data. Relevant Relevant Linda has experienced a number of losses in the last year. She has verbalized feeling very hopeless and has indicated that she is currently experiencing difficulty dealing with stressors at work. Relevant Relevant This client has already attempted suicide. It would be important to assess her current thoughts related to suicide. Relevant Relevant Linda has identified that she has accessed community resources in the past. Linda has also recently lost several key support people. Relevant Relevant Linda has identified that she has had a number of stressors in her life within the last 6 months. Relevant Relevant Assessment Data/Patient Results: Linda identifies that her job is currently the most significant stressor in her life. 6. Assess the recent losses in Linda’s life. Rationale Relevancy Your Answer Recent losses have contributed to Linda’s feelings of social isolation and powerlessness. Relevant Relevant Copyright @2017 by FA Davis Linda Watson | Assess the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. • Psychosocial Assessment • Inspection • Palpation • Auscultation • Percussion 1. Assessing baseline vital signs is important. Although indications are that Linda’s vital signs have been stable, it is important to document assessment information to rule out physiological concerns related to her recent overdose. Relevant Relevant Linda’s acetaminophen overdose could result in liver damage or liver failure; therefore, it would be important to perform a thorough assessment. Relevant Relevant Copyright @2017 by FA Davis Linda Watson | Assess the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. • Psychosocial Assessment • Inspection • Palpation • Auscultation • Percussion Assessing baseline vital signs is important. Although indications are that Linda’s vital signs have been stable, it is important to document assessment information to rule out physiological concerns related to her recent overdose. Relevant Relevant Linda’s acetaminophen overdose could result in liver Relevant Relevant damage or liver failure; therefore, it would be important to perform a thorough assessment. Copyright @2017 by FA Davis Linda Watson | Assess the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. • Psychosocial Assessment • Inspection • Palpation • Auscultation • Percussion Assessing baseline vital signs is important. Although indications are that Linda’s vital signs have been stable, it is important to document assessment information to rule out physiological concerns related to her recent overdose. Relevant Relevant Little useful information can be gleaned from this inspection in the absence of any other physiological complaints. Irrelevant Irrelevant Linda’s acetaminophen overdose could result in liver damage or liver failure; therefore, it would be important to perform a thorough assessment. Relevant Relevant Copyright @2017 by FA Davis Linda Watson | Assess the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. • Psychosocial Assessment • Inspection • Palpation • Auscultation • Percussion Linda’s acetaminophen overdose could result in liver damage or liver failure; therefore, it would be important to perform a thorough assessment. Relevant Relevant Based on the information collected in the interview process, there is nothing to indicate that Linda has a neurological deficit. Irrelevant Irrelevant Copyright @2017 by FA Davis Linda Watson | Labs / Diagnostic Tests | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. 1. CXR (Chest X-Ray) Rationale Relevancy Your Answer Not of value when diagnosing or treating an overdose. Irrelevant Irrelevant 2. Acetaminophen Level Rationale Relevancy Your Answer The client overdosed on acetaminophen. It is important to monitor the levels to ensure that she is not within toxic range. Relevant Relevant 3. Liver Function Tests Rationale Relevancy Your Answer Clients who overdose on acetaminophen may go into liver failure or experience liver damage as a result of the overdose. Relevant Relevant 4. Kidney Function Tests Rationale Relevancy Your Answer Clients who overdose on acetaminophen may experience kidney damage as a result of the overdose. Relevant Relevant 5. MRI Rationale Relevancy Your Answer There is no indication that an MRI would be required at this time Irrelevant Irrelevant 6. CAT Scan Rationale Relevancy Your Answer There is no indication that a CAT scan would be required at this time. Irrelevant Irrelevant 7. Prothrombin Time (PT) and International Normalized Ratio (INR) Rates Rationale Relevancy Your Answer If liver damage has occurred, the client may experience serious bleeding problems as a result of changes to clotting time. Relevant Relevant 8. Abdominal Ultrasound Rationale Relevancy Your Answer To assess for kidney and/or liver damage and establish a baseline. Relevant Relevant Copyright @2017 by FA Davis Linda Watson | Clustering Assessment Data | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. When you are finished reviewing, click "Continue" to proceed to next section. 1. Cluster A Rationale Correct Answer Your Answer Rationale: It is important to monitor the client’s mental health status and assess for ongoing suicidal ideation and suicidal plans. Linda is slightly anxious and states that she feels embarrassed and ashamed of her actions. Linda states that she has lost much of her support network in the last year and has no one to turn to. Linda states that she feels her life will not get any better. She is feeling very hopeless at the present time. Linda identifies that she just wants her life to get better. She is feeling hopeless and helpless at the present time, but states that she does not have a suicide plan at the present time. Linda is slightly anxious and states that she feels embarrassed and ashamed of her actions. Linda states that she has lost much of her support network in the last year and has no one to turn to. Linda states that she feels her life will not get any better. She is feeling very hopeless at the present time. Linda identifies that she just wants her life to get better. She is feeling hopeless and helpless at the present time, but states that she does not have a suicide plan at the present time. 2. Cluster B Rationale Correct Answer Your Answer Rationale: The client’s support network and knowledge of available community resources will enable the health-care professional to plan for discharge. Linda identified several friends who have been supportive and who she enjoyed socializing with. Linda states that she feels her counselor in the community was helpful in the past. Linda discussed her reluctance to talk about her feelings with her daughter, stating that she did not want to worry her. Linda states that she no longer participates in activities she used to enjoy because she just doesn’t have the Linda identified several friends who have been supportive and who she enjoyed socializing with. Linda states that she feels her counselor in the community was helpful in the past. Linda discussed her reluctance to talk about her feelings with her daughter, stating that she did not want to worry her. Linda states that she no longer participates in activities she used to enjoy because she just doesn’t have the energy. energy. 3. Cluster C Rationale Correct Answer Your Answer Rationale: Identification of the client’s stressors and losses assists clients to identify areas of control in their lives. Linda identifies that her job is currently the most significant stressor in her life. Linda identifies the recent losses she has experienced and verbalizes that these losses have contributed to her sense of isolation and loss of control. Linda states that she feels as if she has no control over her work situation and is worried that she will soon lose her job. Linda becomes very upset, teary, and anxious when she discusses her relationship with her work colleagues. Linda identifies that her job is currently the most significant stressor in her life. Linda identifies the recent losses she has experienced and verbalizes that these losses have contributed to her sense of isolation and loss of control. Linda states that she feels as if she has no control over her work situation and is worried that she will soon lose her job. Linda becomes very upset, teary, and anxious when she discusses her relationship with her work colleagues. Copyright @2017 by FA Davis Linda Watson | Assign Diagnoses | Review Back Continue Answers and Rationale Your responses are displayed below. When you are finished reviewing, click "Continue" to proceed to next section. 1. Cluster A Rationale Correct Answer Your Answer True Risk for Suicide Risk for Suicide 2. Cluster B Rationale Correct Answer Your Answer True Social Isolation Social Isolation 3. Cluster C Rationale Correct Answer Your Answer True Powerlessness Powerlessness Copyright @2017 by FA Davis Linda Watson | Nursing Outcomes / Individualized Goals | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. 1. Client will not harm self. Rationale Relevancy Your Answer Rationale: Client safety is a priority. Clients who have had a previous serious suicide attempt are at higher risk for subsequent suicide attempts. Risk for Suicide Risk for Suicide 2. Client will seek out staff, support people, or community resources when feeling the urge to harm self. Rationale Relevancy Your Answer Rationale: Client safety is a priority. Clients who have had a previous serious suicide attempt are at higher risk for subsequent suicide attempts. Risk for Suicide Risk for Suicide 3. The client will spend time socializing and interacting with nursing staff and other patients on the unit. Rationale Relevancy Your Answer Rationale: Establishing social interactions with co-patients and nursing staff enables the client to reestablish her social skills. Social Isolation Social Isolation 4. The client will identify support people in her life and reach out to them. Rationale Relevancy Your Answer Rationale: The client has identified that she has isolated herself from those who have been supportive in the past. Reestablishing that support network will be an important Social Isolation Social Isolation factor in planning for discharge. 5. Client will begin to participate in decision-making regarding her discharge plan. Rationale Relevancy Your Answer Rationale: Active participation in discharge planning enables clients to feel a sense of control over their lives. Powerlessness Powerlessnes s 6. Client will begin to demonstrate problem-solving strategies that will enable her to feel in control of her life. Rationale Relevancy Your Answer Rationale: Clients who develop successful problem- solving strategies will experience a feeling of accomplishment and enhance their self-esteem. Powerlessness Powerlessne ss Copyright @2017 by FA Davis Linda Watson | Nursing Interventions / Activities | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. 1. Encourage client attendance at group activities. Rationale Relevancy Your Answer Rationale: Group therapies enable clients to identify with other individuals, recognizing that others are in crisis as well and learning from them how to cope with life stressors. Social Isolation Social Isolation 2. Encourage the client to begin making decisions regarding her care, establishing realistic goals for discharge. Rationale Relevancy Your Answer Rationale: Successful decision-making will promote client self-esteem and a sense of control over her life. Powerlessness Powerlessnes s 3. Perform a suicide risk assessment. Rationale Relevancy Your Answer Rationale: The client’s risk for suicide increases if she has developed a plan. Risk for Suicide Risk for Suicide 4. Assist the client with identifying areas of her life over which she has control. Rationale Relevancy Your Answer Rationale: Focusing on areas of her life that she can control will enable the client to develop strategies to deal with those issues. Powerlessness Powerlessne ss 5. Encourage the client to verbalize her feelings. Rationale Relevancy Your Answer Rationale: This intervention assists the client to learn how to honestly and openly express her feelings, reaching out for support when she begins to feel overwhelmed. Risk for Suicide Risk for Suicide 6. Identify resources that the client can access and encourage her to do so if her mood changes. Rationale Relevancy Your Answer Rationale: Clients who have a plan and resources available will seek out resources when thinking of harming themselves. Risk for Suicide Risk for Suicide 7. Assist the client with identifying supportive people in her past. Rationale Relevancy Your Answer Rationale: Clients can reestablish previous support networks and also learn how to establish new support networks that will assist them with coping strategies. Social Isolation Social Isolation Copyright @2017 by FA Davis