Ouestion: Scenario: Daniel, a 73 years old, came to the... Scenario: Daniel, a 7
ID: 238820 • Letter: O
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Ouestion: Scenario: Daniel, a 73 years old, came to the... Scenario: Daniel, a 73 years old, came to the emergency room with a temperature of 1 complained of abdominal pain. He rated the pain at 10 on a scale of 1-10. He was admitted and 00.2 F. He sed with urinary tract infection and urosepsis. Past medical history includes prostate Daniel reports incontinence related to having a indwelling foley catheter during chemotherapy for about 3 weeks. It was removed last week. The RN obtained only 30 mL of dark brown urine, with no visible blood noted when the patient was catheterized with an 18 Fr Foley catheter in the emergency room. Daniel reported that he has not been drinking fluids because it hurts when try to go. He reported not unintentional weight loss or gain of 10 pounds or greater. Upon inspection, no visible edema. Upon palpation, no edema noted. A saline lock was placed in the left forearm for antibiotic therapy, it is patent and free of signs of infection. Answer the following questions. Question 1 The nursing process is a valuable tool for RN to use in practice to ensure the best possible care for your patients. Assess and observe both physiologic and psychological needs of the patient. Describe the problem and provide supporting data for its identification Focus on problems that are controllable Use outcome (NOC) to identify goals that are plausible and measurable .Use scientific principles and rationale to develop alternative courses of actions Perform safe and effective nursing care Document the effectiveness of the plan of care for the individual patient based on current problems and abnormal signs and symptoms Develop nursing diagnoses based on facts and supporting data according to NANDA Use interventions (NIC) to identify nursing interventions in response related to the nursing diagnoses Establish a plan of care outlining appropriate independent, dependent andfor interdependent nursing actions based on assessment data and analysis for goal attainment. Evaluate extent to which goals had been achieved Review, modify, or resolve plan of care. Question 2 Underline all the cues and problems in the scenario. Cluster the relevant data into groups Identify and prioritize 3 nursing diagnosis What goal or goals do you expect for this patientExplanation / Answer
1. Answer is option A Any intentional weight loss or gain would not be included in the patient teaching.
2. Answer is option C
3. Answer is option A. Fluid volume deficit is not an increase in intracellular, interstitial or intravascular fluid level.
4. Answer is option D knowledge deficit, dysuria and decreased urinary output is the risk factors of patient.
5. Answer is option A. Patient with hypotension, weak pulse and thready pulse may have increased body temperature.
7. Answer is option C urine specific gravity is 1.000 -1.030is normal. 1.036 indicate dehydration.
8. Answer is option B. The amount of urine the patient should excreted to remove the waste is 400 -600 ml
9. Answer is option A. The specific gravity of urine increasing when patient become dehydrated
10. Answer is option D. Oliguria is the decrease in urine output less than 30ml /hr and which persist untreated may lead to acute renal failure. I
11. Answer is option A Normal BUN value is up-to 20 mg/dl. Patient s value is 30. So nurse should notify the physician.
12. Answer is option A Promoting the skin integrity of the patient is the primary concern of the staff.
13. Answer is option D. Defining characteristics are not a part of nursing diagnosis.
14. Answer is option B. Provide psychological support to the patient is a nurse initiated intervention.
15. Answer is option C The effect of Medical diagnosis.
16. Answer is option C . The patient is normotensive from preoperative bowel preparation.
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