Devin Hershell 39-years-old: Attempt review 8/24/23 7:43 a. m.
Portal Ca ® A Daniela Lima _
Dashboard / Mental Health Care Unit / Devin Hershell 39-years-old
& _Dashboard
Started on Thursday, August 24, 2023, 6:37 AM
B _My Activity
State Finished
Y _Grades
Completed on Thursday, August 24, 2023, 6:43 AM
B _NurseThink® CJSim Tutorial
Time taken 5 mins 27 secs
BB _Med Room
Grade 100.00 out of 100.00
BB _Fundamentals
B8 _Skilled & Long Term Care Unit Question 1 Complete 33.34 points out of 33.34
BB _Medical Care Unit
@8 _Surgical Care Unit Name: Devin Hershell Age: 39 years Provider: G. House MD
Code Status: Full code Admit Wit: 180 Ibs (31.8 kg) BMI: 23.7
BB _Pediatric Care Unit
Allergies: Unknown
B _Maternal-Child Care Unit
( Nursing T Providerw
B Mental Health Care Unit
NURSING ASSESSMENT & NOTES
B8 _Stepdown & Critical Care Unit
7/23 Nursing Note: Appears oppositional and irritable upon assessment. Refused to
Pre-hospital & Emergency 2200 cooperate with intake questions. Observed pacing up and down the hallway,
“Care Unit talking to himself. He keeps asking for a "Beer or something stronger." Informed
M dim oAdimn;mdt O MNanmns it s on-call psychiatrist of new admission and received prescriptions for emergency
medications. Keeping the client in line of sight due to increased irritability. Client
yelling at nurses when contact is attempted. Security informed and is on the
unit. Vital signs were not obtained due to client refusal. He is currently missing
the morning coping skills group.
7/23 Nursing Note: Pharmacy delivered appropriate emergency medications;
2330 behavior continued to escalate as evidence but consistently yelling at staff and
the walls in the hallways, noted to begin hitting his head repeatedly with his
hands, and began opening and slamming doors shut in the hallways; shouting
vulgarities when the engagement was attempted. Began making statements,
"I'm going to kill each one of you unless you let me go — I'll kill myself too."
Prepared haloperidol and lorazepam; with the aid of security, approached and
requested he go to his room to calm down. The client began yelling and
charging at staff. We utilized PMAB (Prevention and Management of Aggressive
Behavior) interventions, and client was placed in seclusion room. Administered
IM meds in the right gluteal; remained in hold for approx. 2 minutes. Assessed
respiration and the airway remained open and clear. Provided criteria for hold
release, which included demonstrating calm behavior such as keeping arms
https://learning.nursethink.com/mod/quiz/review.php?attempt=949724&cmid=684 Pagina1de 5
, Devin Hershell 39-years-old: Attempt review 8/24/23 7:43 a. m.
ana l1egs stil ana aecreasing nNis voICe volume. AT The Z-minute mark notea he
had stopped struggling with staff. Informed him that he would be released and
requested to stay lying or seated on the floor. He stated "OK" and was released
from hold. With staff support, walked to his room, and laid down on his bed. The
technician sat outside of the doorway, keeping him within line of sight.
Before answering this question, review the client's health information in the EHR. Identify
each finding as concerning or not concerning. Select one answer in each row.
Concerning Not Concerning
Increasing agitation.
Potential for violence toward others.
Use of cocaine.
Vital signs not completed.
Missing coping skills group.
Assessment incomplete.
Escalating behaviors.
Suicidal ideations.
Consider:
1. What behaviors are consistent with escalation? What strategies might be effective
in de-escalation?
2. ldentify the client's suicidal ideations. What additional statements would validate
these intentions?
3. What nursing actions are indicated because the medications are not in the
automated medication dispenser yet or not available when needed?
Question 2 Complete 33.33 points out of 33.33
Name: Devin Hershell ~ Age: 39 years Provider: G. House MD
Admit Wt: 180 Ibs (31.8
Code Status: Full code BMI: 23.7
kg)
Allergies: Unknown
( Nursing T Provider\( Collaborative Care)
https://learning.nursethink.com/mod/quiz/review.php?attempt=949724&cmid=684 Pagina 2 de 5
Portal Ca ® A Daniela Lima _
Dashboard / Mental Health Care Unit / Devin Hershell 39-years-old
& _Dashboard
Started on Thursday, August 24, 2023, 6:37 AM
B _My Activity
State Finished
Y _Grades
Completed on Thursday, August 24, 2023, 6:43 AM
B _NurseThink® CJSim Tutorial
Time taken 5 mins 27 secs
BB _Med Room
Grade 100.00 out of 100.00
BB _Fundamentals
B8 _Skilled & Long Term Care Unit Question 1 Complete 33.34 points out of 33.34
BB _Medical Care Unit
@8 _Surgical Care Unit Name: Devin Hershell Age: 39 years Provider: G. House MD
Code Status: Full code Admit Wit: 180 Ibs (31.8 kg) BMI: 23.7
BB _Pediatric Care Unit
Allergies: Unknown
B _Maternal-Child Care Unit
( Nursing T Providerw
B Mental Health Care Unit
NURSING ASSESSMENT & NOTES
B8 _Stepdown & Critical Care Unit
7/23 Nursing Note: Appears oppositional and irritable upon assessment. Refused to
Pre-hospital & Emergency 2200 cooperate with intake questions. Observed pacing up and down the hallway,
“Care Unit talking to himself. He keeps asking for a "Beer or something stronger." Informed
M dim oAdimn;mdt O MNanmns it s on-call psychiatrist of new admission and received prescriptions for emergency
medications. Keeping the client in line of sight due to increased irritability. Client
yelling at nurses when contact is attempted. Security informed and is on the
unit. Vital signs were not obtained due to client refusal. He is currently missing
the morning coping skills group.
7/23 Nursing Note: Pharmacy delivered appropriate emergency medications;
2330 behavior continued to escalate as evidence but consistently yelling at staff and
the walls in the hallways, noted to begin hitting his head repeatedly with his
hands, and began opening and slamming doors shut in the hallways; shouting
vulgarities when the engagement was attempted. Began making statements,
"I'm going to kill each one of you unless you let me go — I'll kill myself too."
Prepared haloperidol and lorazepam; with the aid of security, approached and
requested he go to his room to calm down. The client began yelling and
charging at staff. We utilized PMAB (Prevention and Management of Aggressive
Behavior) interventions, and client was placed in seclusion room. Administered
IM meds in the right gluteal; remained in hold for approx. 2 minutes. Assessed
respiration and the airway remained open and clear. Provided criteria for hold
release, which included demonstrating calm behavior such as keeping arms
https://learning.nursethink.com/mod/quiz/review.php?attempt=949724&cmid=684 Pagina1de 5
, Devin Hershell 39-years-old: Attempt review 8/24/23 7:43 a. m.
ana l1egs stil ana aecreasing nNis voICe volume. AT The Z-minute mark notea he
had stopped struggling with staff. Informed him that he would be released and
requested to stay lying or seated on the floor. He stated "OK" and was released
from hold. With staff support, walked to his room, and laid down on his bed. The
technician sat outside of the doorway, keeping him within line of sight.
Before answering this question, review the client's health information in the EHR. Identify
each finding as concerning or not concerning. Select one answer in each row.
Concerning Not Concerning
Increasing agitation.
Potential for violence toward others.
Use of cocaine.
Vital signs not completed.
Missing coping skills group.
Assessment incomplete.
Escalating behaviors.
Suicidal ideations.
Consider:
1. What behaviors are consistent with escalation? What strategies might be effective
in de-escalation?
2. ldentify the client's suicidal ideations. What additional statements would validate
these intentions?
3. What nursing actions are indicated because the medications are not in the
automated medication dispenser yet or not available when needed?
Question 2 Complete 33.33 points out of 33.33
Name: Devin Hershell ~ Age: 39 years Provider: G. House MD
Admit Wt: 180 Ibs (31.8
Code Status: Full code BMI: 23.7
kg)
Allergies: Unknown
( Nursing T Provider\( Collaborative Care)
https://learning.nursethink.com/mod/quiz/review.php?attempt=949724&cmid=684 Pagina 2 de 5
