Cluster Clues
A patient has a grimace on their face and they are guarding their abdomen. Their heartrate and respirations are elevated, blood pressure mildly elevated, and pupils are wide. The autonomic nervous system that explains these symptoms is:
What is the sympathetic nervous system (part of the autonomous).
Body has autopilot for fight-or-flight response. Here the patient has pain as evidenced by grimace and guarding. Sympathetic response = speedy
(Increase heartrate, increase respirations, pupils open to let in more light)
Turning to drugs, alcohol, risky behaviors are all examples of ___________ coping skills.
What are unhealthy coping skills or negative coping skills.
All older adults are forgetful, confused, rigid, boring, and unfriendly. This is an example of:
What is common myth or stereotypes about older adults.
The fourth stage of Kubler-Ross' Stages of Dying
What is depression?
DABDA
Denial, Anger, Bargaining, Depression, Acceptance
Describe sleep history questions that help you assess your patient's quality and amount of sleep:
What are:
Description of sleep, usual sleep pattern/hrs, physical discomforts, current life events, emotional/mental status, sleep routines, bedtime environment, behaviors, etc.....
Three developmental tasks older adults must cope with include:
changes in health, usefulness, socialization, income, independent living, retirement, death of spouse, etc
You work on a medical-surgical unit and your patient is hooked up to continuous GI suctioning. On assessment, you note restlessness, decreased LOC, complaints of dizziness, and the patient complains of muscle cramps. You identify these symptoms as abnormal and name it:
dysrythmias-tachycardia, n/v/d which here includes too much suctioning of stomach, compensatory hypoventilation to keep CO2 in body to correct the alkalosis.
The ability to concentrate, make judgments, and participate in daily activities requires adequate ________ and nutrition.
What is sleep and/or rest?
A pre-school teacher asks about normal sleep time for her students to gain insight to their needs. The teacher has a few students that come in each morning extremely tired and cranky and just want to sleep for hours. The number of hours a preschool child should sleep per night is:
What is 12 hours per night.
While the exact number may not be so important, the trends with the different age groups is so that we can teach parents to enforce routine bedtimes so that their child gets enough sleep and rest for their growing bodies.
A patient presents with heart failure and is getting treatment in the acute care setting. He asks his nurse if he can take his "water pill" later in the day. You would educate the patient about ___________ that would affect their ability to sleep well.
Many disruptions can cause sleep issues in the acute care setting including lights, noises, roommates, change of environment, staff waking, etc. Learning ways to help patients get rest can help them heal quicker.
A parents asks the pediatrician about their child's nighttime problems. They describe periods where the child walks in the house in the middle of the night and the parent can not wake them. They state, "It looks like my child is just staring right through me." The child is exhibiting signs of:
What is a parasomnia called sleepwalking (somnambulism)
You are teaching your patient what foods to include in their diet to correct hypokalemia. You would list:
What are:
fruits, potatoes, instant coffee, molasses, brazil nuts. (most people just say bananas and that is good, but not enough)
The hormone response to fluid & electrolyte balance that regulates salt and water is:
What is the Renin-Angiotensin-Aldosterone System (RAAS) and/or Atrial Natriuretic Peptide (ANP)?
Interplay of hormones helps maintain homeostasis.
During pain assessment, the PQRST method stands for:
Palliative or Provocative (what makes better/worse)
Quality: describe your pain
Region: show me where you hurt
Severity: 0-10, Faces scale
Timing: constant, intermittent, when worse?
What are normal physiological changes?
A patient presents with hyperkalemia, headache, warm and flushed skin, n/v/d, confusion and Kussmaul respirations. Some of the causes of this acid-base imbalance are:
(First identify imbalance as Metabolic Acidosis)
What are Diabetic Ketoacidosis (DKA), severe diarrhea, renal failure, and shock?
Acute state of confusion is called this.
What is delirium?
(delirium-acute; dementia-general impairment)
Patient has signs of phlebitis. Stop infusing and call your physician for further orders.
Other IV complications: infiltration & extravasation
Know nursing interventions for these conditions.
You are analyzing ABG values and find the patient has:
pH 7.55, PaCO2 26, HCO3 20
What is respiratory alkalosis?
S/S: seizures, lethargy, confusion, deep/rapid breathing (hyperventilation), tachycardia, hypokalemia, numbness/tingling of extremities, light headedness, n/v
Condition: hyperventilation, anxiety, fear, PE, mechanical ventilation
You enter your patient's room and notice that the respirations are shallow and slow. The patient is drowsy after their surgery and have a PCA pump of morphine in progress. You would suspect:
What is oversedation and respiratory depression.
Close monitoring of patients pain management is the nurses responsibility. Check often and follow-up with issues. With PCA, only patient pushes button (educate patient and family)! If you suspect overdose, stop PCA pump immediately and initiate priority interventions for safety.
What is elder abuse or elder mistreatment.
It is the nurses job to recognize symptoms, assess, and report elder abuse.
In starting a blood transfusion, two nurses thoroughly check identifiers for verification. After beginning the transfusion, the nurse notes that the patient complains of itching and chest pain. You examine the vital signs and note an increase in temperature and the patient begins to shiver. The patient gets anxious and expresses feeling their heart race. The patient is experiencing:
What is a blood transfusion reaction?
STOP THE INFUSION. Stay with patient. Notify charge nurse. Involve rapid response/MD. Keep all tubing and blood bag to send back to lab.
The normal values used for arterial blood gas (ABG):
pH 7.35-7.45
PaCO2 45-35
HCO3 21-28
Evaluate these values and tell which is not within normal limits:
sodium 136-145
potassium 3.5-5.0
bicarbonate 21-28
calcium 8.0-9.0
What is calcium?
Normal value is 9.0-10.5
A patient presents with the following vital signs and lab work: bp 85/40, pulse 95, resp 10 and shallow. The ECG shows dysrhythmia and DTR are 3+. As you are asking the family questions, the family states that they found the patient with a bottle of pills next to them. ABGs show pH 7.2, PaCO2 60, and HCO3 35. This patient has:
What is respiratory acidosis.
Common symptoms hypoventilation (not enough CO2 expelled), decreased bp (b/c acidotic), dyspnea, hyperkalemia, dysrythmias, hyperreflexia.
Conditions: anesthesia, drug overdose, COPD, pneumonia, atelectasis