BSN 225 - Sherpath - NGN Case Study: Vital Signs Questions & Answers Already Graded A+

Patient 1 1600 An older adult client is admitted to the medical unit from the emergency department (ED) after being found alone in the home after a recent abnormally cold weather event. A neighbor, checking on the client, found that the heat was not on and the temperature in the apartment was 13.9 °C (57 °F). The client was shivering slightly, had slurred speech, and appeared drowsy. Skin dry, pale, cold to touch. The client is admitted to the medical unit from the emergency department. The nurse reviews the admission data and healthcare providers' orders. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two relevant cures assessed, and two actions the nurse should take to address that condition. - CORRECT ANSWER-Relevant Cues - T 34.44C (94.4F) - Skin dry, pale, cold to touch Potential Conditions - Hypothermia Actions to Take - Place the client on a warming blanket - Monitor vital signs every 15 minutes Patient 2 A 65-year-old client is seen in the emergency department (ED) today with extreme headaches, which have been occurring daily for the last week. There is no prior history of high blood pressure. The client denies taking antihypertensive medication, steroids, appetite suppressants, tricyclic antidepressants, monoamine oxidase inhibitors, cocaine, and other drugs. The client states using nonsteroidal anti-inflammatory drugs (NSAIDS) and over-the-counter cold medication, if needed. No history of diabetes, heart disease, kidney disease, dyslipidemia, or tobacco use. Occasional, social alcohol intake. Indicates regular intake of processed, frozen foods. Family history significant for hypertension (father). Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. - CORRECT ANSWER-The aspect of the client's admission history that is most concerning to the nurse is: extreme headaches occurring daily.Physical examination findings that require immediate follow-up include: BP of 168/94 respiratory rate of 28 Patient 2 The nurse repeats the client's vital signs and documents the results in the flow sheet. For each vital sign measured at 1315, click to indicate whether the findings are within, below, or above expected ranges for this client. Each row must have only one response option selected. - CORRECT ANSWERTemperature - Within Expected Range Pulse - Above Expected Range Respiratory Rate - Above Expected Range Blood Pressure - Above Expected Range Oxygen Saturation - Below Expected Range Patient 2 Client identifies that there is no prior history of antihypertensive medication use. Client denies knowledge of drug effects and medication precautions. Client states currently experiencing a headache, 4 on a numeric 0-to-10 pain scale. Client takes chlorthalidone and lisinopril tablets without difficulty. The nurse administers the initial doses of medication as prescribed and documents in the Nurses' Notes. Drag from Word Choices to complete the sentence. - CORRECT ANSWER-The nurse identifies the priority client problems as: insufficient knowledge of medications pain reduced oxygenation altered cardiac output The nurse collaborates with the client when developing a plan of care and identifying short- and long-term treatment goals. Select 4 outcomes for this client based upon the client history, physical examination, and nursing assessment data. - CORRECT ANSWER-1. Client will have a blood pressure (BP) below 170/90 an hour after medication administration. 2. Client will have improved oxygen capacity with use of medication regimen. 3. Client will participate in activities that will prevent stress. 4. Client will consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of sodium and fat.The client experiences dizziness several hours after administration of antihypertensive medication on hospital day 2, which the nurse documents in the Nurses' Notes. Drag one condition and one client finding to complete the sentence. - CORRECT ANSWER-The nurse determines that the client is experiencing: orthostatic hypotension as a result of medication side effects. The nurse completes morning rounds and medication administration on hospital Day #3 and documents the client's status in the flow sheet and Nurses' Notes. Select the 4 assessment parameters that indicate client improvement as documented by the nurse. - CORRECT ANSWER-Pulse Respirations Blood pressure Knowledge of medications