Finals Reviewer
Illnesses/Medications
Therapeutic Tools for enhancing communication
communication/techniques – 6 ➢ Using silence
questions: various illnesses/client ➢ Refer back to the previous
situation topic that was discussed.
➢ Active listening
➢ Clarifying techniques
➢ Focus on their perspective of
what’s going on
➢ Establish rapport
• Addiction – 5 questions ➢ S/S of alcohol withdrawal:
➢ Opioid abuse – 2 a. Increased HR, BP
➢ Etoh abuse – 3 b. Confusion
c. Disorientation
Including thiamine deficiency,
➢ CIWA-AR
CIWA-AR Scale - when to begin
• The maximum score is
the detox protocol
67
• Mild alcohol withdrawal
is defined with a score
≤10
• Moderate with scores 11
to 15
• Mild and moderate
scores – Continue with
Benzos
• Severe with any score ≥
16
• ≥ 16 – Benzos PR
➢ Elevated pulse and blood
pressure may indicate
impending alcohol withdrawal
, and the need for detox with
medical intervention to prevent
a hypertensive crisis and/or
seizures.
➢ When stable, provide
information about rehab – AA
➢ Self-help group for people to
share experiences with
alcoholism and recovery
➢ Patient outcome prior to d/c
• Patient will state* “I know I
need long-term treatment*
➢ Best goal related to controlling
relapse
➢ Rehab Challenge
▪ Sobriety solves some
problems
▪ New ones may emerge
as one adjusts to living
without drugs and alcohol
➢ Wernicke encephalopathy and
Korsakoff syndrome
- Long-term heavy alcohol use
- Brain damage caused by a lack
of vitamin B1
- (Thiamine) [from a deficiency in
vitamin B complex].
• Child abuse – 1 question ➢ Younger than 3 years
➢ Perceived as different
➢ Remind parents of someone
they do not like
➢ Product of an unwanted
pregnancy
, ➢ Interference with emotional
bonding between parent and
child
➢ The child is under 4 years of
age.
➢ The perpetrator perceives the
child as being different
➢ The child is the result of an
unwanted pregnancy
- Is physically disabled
- Has some other trait that
makes them particularly
vulnerable
Nursing Care:
- All states have mandatory
reporting laws that require nurses to
report suspected child or vulnerable
adult abuse;
• Civil and criminal penalties for
not reporting suspicions of
abuse.
- Document subjective and
objective data obtained during
assessment
- Provide basic care to treat
injuries.
- Make appropriate referrals.
*Help client develop a safety plan
- Identify behaviors and situations
that might trigger violence and
provide information regarding safe
places to live.
- Use crisis intervention
techniques to help resolve
family or community situations
, where violence has been
devastating.
• Abuse – 1 question ❖ Be empathetic, objective,
and nonjudgmental.
❖ Allow another nurse to
care for the client if
feeling emotional about
the assault
❖ Client’s level of anxiety,
coping mechanisms, and
available support
systems.
❖ Assess for indications of
emotional and/or physical
trauma.
❖ A sexual assault nurse
examiner (SANE)
❖ *Administer prophylactic
treatment for sexually
transmitted infections as
outlined by the Centers
for Disease Control and
Prevention.
• IPV – 1 question ➢ Self-esteem disturbances
A young female has experienced Phases
partner violence. The client is ➢ Tension – building cycle
most likely at risk for the following
➢ Acute battering phase
findings: ➢ Honeymoon phase
• ECT – 2 questions ➢ The most effective depression
treatment
➢ Use when patient is
unresponsive to other
treatments
Illnesses/Medications
Therapeutic Tools for enhancing communication
communication/techniques – 6 ➢ Using silence
questions: various illnesses/client ➢ Refer back to the previous
situation topic that was discussed.
➢ Active listening
➢ Clarifying techniques
➢ Focus on their perspective of
what’s going on
➢ Establish rapport
• Addiction – 5 questions ➢ S/S of alcohol withdrawal:
➢ Opioid abuse – 2 a. Increased HR, BP
➢ Etoh abuse – 3 b. Confusion
c. Disorientation
Including thiamine deficiency,
➢ CIWA-AR
CIWA-AR Scale - when to begin
• The maximum score is
the detox protocol
67
• Mild alcohol withdrawal
is defined with a score
≤10
• Moderate with scores 11
to 15
• Mild and moderate
scores – Continue with
Benzos
• Severe with any score ≥
16
• ≥ 16 – Benzos PR
➢ Elevated pulse and blood
pressure may indicate
impending alcohol withdrawal
, and the need for detox with
medical intervention to prevent
a hypertensive crisis and/or
seizures.
➢ When stable, provide
information about rehab – AA
➢ Self-help group for people to
share experiences with
alcoholism and recovery
➢ Patient outcome prior to d/c
• Patient will state* “I know I
need long-term treatment*
➢ Best goal related to controlling
relapse
➢ Rehab Challenge
▪ Sobriety solves some
problems
▪ New ones may emerge
as one adjusts to living
without drugs and alcohol
➢ Wernicke encephalopathy and
Korsakoff syndrome
- Long-term heavy alcohol use
- Brain damage caused by a lack
of vitamin B1
- (Thiamine) [from a deficiency in
vitamin B complex].
• Child abuse – 1 question ➢ Younger than 3 years
➢ Perceived as different
➢ Remind parents of someone
they do not like
➢ Product of an unwanted
pregnancy
, ➢ Interference with emotional
bonding between parent and
child
➢ The child is under 4 years of
age.
➢ The perpetrator perceives the
child as being different
➢ The child is the result of an
unwanted pregnancy
- Is physically disabled
- Has some other trait that
makes them particularly
vulnerable
Nursing Care:
- All states have mandatory
reporting laws that require nurses to
report suspected child or vulnerable
adult abuse;
• Civil and criminal penalties for
not reporting suspicions of
abuse.
- Document subjective and
objective data obtained during
assessment
- Provide basic care to treat
injuries.
- Make appropriate referrals.
*Help client develop a safety plan
- Identify behaviors and situations
that might trigger violence and
provide information regarding safe
places to live.
- Use crisis intervention
techniques to help resolve
family or community situations
, where violence has been
devastating.
• Abuse – 1 question ❖ Be empathetic, objective,
and nonjudgmental.
❖ Allow another nurse to
care for the client if
feeling emotional about
the assault
❖ Client’s level of anxiety,
coping mechanisms, and
available support
systems.
❖ Assess for indications of
emotional and/or physical
trauma.
❖ A sexual assault nurse
examiner (SANE)
❖ *Administer prophylactic
treatment for sexually
transmitted infections as
outlined by the Centers
for Disease Control and
Prevention.
• IPV – 1 question ➢ Self-esteem disturbances
A young female has experienced Phases
partner violence. The client is ➢ Tension – building cycle
most likely at risk for the following
➢ Acute battering phase
findings: ➢ Honeymoon phase
• ECT – 2 questions ➢ The most effective depression
treatment
➢ Use when patient is
unresponsive to other
treatments
