Med/surg clinical case study Assignment | College Homework Help

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NUR121L Medical-Surgical Nursing I Clinical Case Study

Student Name: _______________________________________________________

Nursing Assessment

Mr. Chuck Rhodes is admitted to the medical-surgical unit for unrelenting abdominal pain. Mr. Rhodes is a 37-year-old fireman. He has been intermittently vomiting for the past 2 days. His wife has accompanied him to the hospital. Mr. Rhodes has never been hospitalized. Crystal is the student nurse who has been assigned to admit Mr. Rhodes. Crystal is in her first clinical rotation. Crystal goes into Mr. Rhodes’ room, introduces herself, and explains that she will be collecting information that is needed for his admission. Mr. Rhodes is agreeable and asks Crystal to call him Chuck.

Answer the following questionsand give the rationale:

  1. Crystal starts the data collection. What would she want to accomplish during the interview? (Select all that apply.)
    A. Establish a caring, therapeutic relationship with Chuck and his wife.
    B. Determine what Chuck’s goals and expectations are regarding hospitalization.
    C. Gain insight about Chuck’s concerns and worries.
    D. Determine Chuck’s medical diagnosis.
    E. Obtain cues about which parts of the interview may require further investigation.

 

Answer: ___________________________________________________________________________

Rationale: _______________________________________________________________________________

__________________________________________________________________________________________

  1. During the initial interview, Crystal notices that Chuck is grimacing and will not make eye contact with her. She wants to get more information. Which question is most appropriate to help Crystal in her assessment?
  2. Do you hurt?
  3. Do you feel like you are going to vomit?
  4. How are you feeling now?
  5. Do you need pain medicine?

Answer: _________________________________________________________________________________

Rationale: _______________________________________________________________________________

__________________________________________________________________________________________

 

  1. Crystal is assessing Chuck using Gordon’s functional health patterns. This is an example of which approach to comprehensive assessment?

Answer: _________________________________________________________________________________

Rationale: _______________________________________________________________________________

__________________________________________________________________________________________

Nursing Diagnosis

Crystal, a student nurse, is caring for Mr. Chuck Rhodes, a 37-year-old firefighter who was admitted to the medical-surgical unit for unrelenting abdominal pain. He has been intermittently vomiting for the last 2 days and has been unable to eat any solid food. His wife has accompanied him. Mr. Rhodes has never been hospitalized. During her assessment, Mr. Rhodes rated his pain as a 9 on a scale of 0 to 10. Crystal is developing the nursing diagnosis. She reviews her assessments.

 

  1. Which of the following statements are true about nursing diagnosis? (Select all that apply.)
  2. Nursing diagnoses are always based on a physiological problem.
  3. Nursing diagnoses have two parts, which include the diagnostic label and the related factor.
  4. Errors in nursing diagnosing can occur from inadequate assessment.
  5. Nursing diagnoses are focused on the scope of nursing practice.

 

Answer: _____________________________________________________________________________

Rationale: ___________________________________________________________________________

______________________________________________________________________________________

 

  1. Crystal establishes the following nursing diagnoses for Mr. Rhodes. Which one of these nursing diagnoses is best reflective of her assessments?
  2. Nausea related to unknown cause of stomach pain
  3. Imbalanced nutrition: less than body requirements related to decreased ability to ingest food as a result of vomiting

 

Answer: _____________________________________________________________________________

Rationale: ___________________________________________________________________________

______________________________________________________________________________________

 

  1. Crystal now has established a nursing diagnosis. This is an example of which of the following types of nursing diagnoses?
  2. Actual nursing diagnosis
  3. Risk nursing diagnosis
  4. Wellness nursing diagnosis
  5. Health promotional nursing diagnosis

Answer: _____________________________________________________________________________

Rationale: ___________________________________________________________________________

______________________________________________________________________________________

 

Planning Nursing Care

Mr. Rhodes, the patient who was being cared for by Crystal in the previous case study, is diagnosed with appendicitis. The surgeon schedules his surgery for that afternoon at 1300. Crystal continues to develop his care plan. Mr. Rhodes has never had surgery and tells Crystal that the thought of surgery makes him very nervous.

 

  1. Crystal wants to add information to his care plan now that the surgery has been scheduled. Which one of the following is an important expected outcome for Mr. Rhodes regarding surgery?
  2. Is able to describe the importance of postoperative exercises before going to surgery
    B. Demonstrates use of the call bell if he needs something after surgery
    C. Will not vomit after surgery
    D. Learns about postoperative exercises to prevent blood clots

 

Answer: _________________________________________________________________________________

 

Rationale: _______________________________________________________________________________

__________________________________________________________________________________________

 

 

  1. Crystal has two nursing diagnoses on Mr. Rhodes’ care plan. Which of these is the priority for Crystal?
  2. Imbalanced nutrition: less than body requirements related to decreased ability to ingest food as a result of vomiting
    B. Deficient knowledge regarding postoperative care related to lack of exposure to information

 

Answer: _________________________________________________________________________________

 

Rationale: _______________________________________________________________________________

__________________________________________________________________________________________

 

  1. Which of the following interventions is written correctly for Crystal to add to Mr. Rhodes’ care plan?
  1. Provide frequent mouth care
    B. Keep NPO
    C. Reposition in bed every 2 hours
    D. Offer 30 ml of water hourly while awake

 

Answer: _________________________________________________________________________________

 

Rationale: _______________________________________________________________________________

__________________________________________________________________________________________

 

 

Implementing Nursing Care

 

Mr. Rhodes, a firefighter, returns from surgery and has an uneventful evening and night. Crystal, the student nurse, will be caring for Mr. Rhodes this morning. She is planning her morning and determines from his care plan and orders that he will need to ambulate this morning, have his dressing changed, and then be discharged to home.

 

  1. Crystal looks at the preprinted orders that Mr. Rhodes’ physician uses for routine dressing changes on his patients who have had an appendectomy. These are examples of which type of standard nursing interventions?

 

Answer: _________________________________________________________________________________

 

Rationale: _______________________________________________________________________________

__________________________________________________________________________________________

 

  1. After Crystal changes Mr. Rhodes’ dressing, she sits down and documents the dressing change. Is documentation considered direct or indirect care?

 

Answer: _________________________________________________________________________________

 

Rationale: _______________________________________________________________________________

__________________________________________________________________________________________

 

  1. While changing Mr. Rhodes’ dressing, Crystal uses infection control measures. What type of nursing care is this?
  2. Teaching
  3. Lifesaving measures
  4. Activities of daily living
  5. Controlling for adverse reactions

 

Answer: _________________________________________________________________________________

 

Rationale: _______________________________________________________________________________

__________________________________________________________________________________________

 

Evaluation

 

Mr. Rhodes is getting ready to go home from the hospital after an appendectomy. Crystal, his student nurse, is getting things ready for the discharge. Crystal evaluates his goals from the care plan. His diagnosis was determined to be Imbalanced nutrition: less than body requirements related to decreased ability to ingest food as a result of vomiting. The goal that was established for the nursing diagnosis is the following: Patient will ingest 2000 calories/day of a regular diet by discharge.

 

  1. What evaluative measures are appropriate for Crystal to use for this goal? (Select all that apply.)
  2. Measure caloric intake.
  3. Weigh patient to monitor for weight gain or stabilization.
  4. Patient will eat ice cream.
  5. Patient reports no nausea after meals.
  6. Patient has not vomited for past 24 hours.

 

Answer: _________________________________________________________________________________

 

Rationale: _______________________________________________________________________________

__________________________________________________________________________________________

 

  1. Crystal is further evaluating Mr. Rhodes’ care plan. She is confirming that all nurse-sensitive outcomes have been met. Which of the following are nurse-sensitive outcomes? (Select all that apply.)
  2. Pain severity will be reduced.
  3. Length of stay will be 4 days.
  4. Skin is intact.
  5. Patient completes hygiene independently.

 

Answer: _________________________________________________________________________________

 

Rationale: _______________________________________________________________________________

__________________________________________________________________________________________

 

  1. Crystal reviews Mr. Rhodes’ care plan with her instructor. Her instructor asks Crystal to explain why it is important to review the care plan for evaluating the outcomes. How should Crystal respond to this question?

 

Answer: _________________________________________________________________________________

 

Rationale: _______________________________________________________________________________

__________________________________________________________________________________________

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