FA Davis Ryan Rodriguez.

FA Davis Ryan Rodriguez. Erika Hightower Ryan Rodriguez Ryan Rodriguez | Interview the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. 1. Good afternoon, Mr. Rodriguez. My name is Greg, and I will be your nurse today. Rationale Relevancy Your Answer Before any assessments or procedures, the nurse should knock on the door and introduce himself, explain the purpose of the encounter, ensure patient privacy, wash hands, and don appropriate personal protective equipment (PPE). Relevant Relevant Patient: Hey, call me Ryan. Mr. Rodriguez is my dad. We’re not talking right now. I am okay. I don’t know what is going to happen to me. I can’t go back to jail. 2. Why are you so agitated right now? Rationale Relevancy Your Answer This comment could be seen as confrontational and the client could become more agitated and aggressive. Irrelevant Irrelevant Patient: Are you kidding me? The police want to take me to jail. My dad has kicked me out. My mom is probably dying. Don’t you get it? 3. You seem agitated. Tell me what has been happening. Rationale Relevancy Your Answer Asking an open-ended question allows the client to tell his illness narrative and the nurse is then able to assess the client’s mental status. Relevant Relevant Patient: Well, I’ve been living with my dad, but he doesn’t want me there anymore. My mom has been diagnosed with cancer. She’s not doing well, so I can’t live with her either. The police want to arrest me. They said I breached my probation, but I think they are just out to get me. I won’t go back to jail. I can’t. 4. When did you last have medication for your withdrawal symptoms? Rationale Relevancy Your Answer Assess the client’s need for medication to address his withdrawal symptoms. Relevant Relevant Patient: I don’t know, probably about 2 or 3 hours ago. It took the edge off a little, but I’m starting to feel anxious again. 5. Have you been hearing voices? Rationale Relevancy Your Answer Individuals withdrawing from substances sometimes experience auditory and/or visual hallucinations. Relevant Relevant Patient: No. I’m not crazy! 6. Have you ever been a victim of physical or sexual abuse? Rationale Relevancy Your Answer There is no indication that this has been an issue in the past. Irrelevant Irrelevant Patient: What? This is stupid. 7. When was the last time you had a bowel movement? Rationale Relevancy Your Answer This is currently not a priority issue with this client. Irrelevant Irrelevant Patient: Who cares?! 8. Has your drug abuse interfered with your life? Rationale Relevancy Your Answer This question would be more appropriate once the client has settled and is no longer experiencing withdrawal symptoms and is willing to address his addiction issues. Irrelevant Irrelevant Patient: I don’t know. I suppose. Now I don’t have anywhere to live. My dad said he is not dealing with me anymore. The police want to arrest me again, so yeah. But I can’t think about that right now. It just makes me so angry. 9. Can you tell me about your history of drug use? Rationale Relevancy Your Answer Assessing the client’s history of drug abuse can assist with management of withdrawal symptoms. Relevant Relevant Patient: Well, I started smoking pot when I was 13. My parents smoked pot all the time, so I thought why not? I tried coke and ecstasy when I was younger, and lately I’ve been using meth or fentanyl. 10. When was the last time you used drugs or alcohol? Rationale Relevancy Your Answer This question would assess the client’s substance abuse history and assist with the management of withdrawal symptoms. Relevant Relevant Patient: Well, I just smoked a joint last night, before the police showed up. It’s been a day since I used meth. I drank some vodka last night as well, just to take the edge off, you know? Why do you need to know all this? Are you reporting everything to the police? 11. You seem to be getting a little more anxious. Would you like some medication to help with the withdrawal? Rationale Relevancy Your Answer Addressing the client’s increasing agitation and aggression by offering medication can assist with de-escalating his behavior. Relevant Relevant Patient: Yeah, and then just leave me alone. I can’t even think in here. Copyright @2017 by FA Davis Ryan Rodriguez | Assess the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. • Inspection • Auscultation • Palpation • Psychosocial Assessment It is important to assess for agitation and aggression when clients are experiencing Relevant Relevant withdrawal symptoms. Copyright @2017 by FA Davis Ryan Rodriguez | Assess the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. • Inspection • Auscultation • Palpation • Psychosocial Assessment Clients who are experiencing withdrawal symptoms may become agitated and aggressive when their personal space is invaded while doing a physical assessment; therefore, this should be delayed until the client is settled. Irrelevant Irrelevant Copyright @2017 by FA Davis Ryan Rodriguez | Assess the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. • Inspection • Auscultation • Palpation • Psychosocial Assessment Clients who are experiencing withdrawal symptoms may become agitated and aggressive when their personal space is invaded while doing a physical assessment; therefore, this should be delayed until the client is settled. Irrelevant Irrelevant Copyright @2017 by FA Davis Ryan Rodriguez | Assess the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. • Inspection • Auscultation • Palpation • Psychosocial Assessment 1. Perform a mental health status assessment. Establishes a baseline for the client’s mental status. Relevant Relevant Ryan made suicidal threats prior to admission. These suicidal thoughts need to be assessed and documented. Relevant Relevant Ryan is experiencing withdrawal symptoms. He has had periods of agitation and aggression prior to admission and since he was admitted. Relevant Relevant Assessment Data/Patient Results: Ryan is currently slightly agitated but states this has improved since he received medication. 4. Assess Ryan’s willingness to stop using drugs. Rationale Relevancy Your Answer This is not the appropriate time to discuss the client’s willingness to undergo treatment for his addiction issues. Irrelevant Irrelevant Copyright @2017 by FA Davis Ryan Rodriguez | Labs / Diagnostic Tests | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. 1. Drugs of Abuse Screen Rationale Relevancy Your Answer Client is an admitted drug abuser. It would be important to assess for the drugs that he has been using in order to address withdrawal symptoms effectively. Relevant Relevant 2. Liver Function Tests Rationale Relevancy Your Answer Drug and alcohol abuse can result in liver damage; therefore, this should be assessed and a baseline established. Relevant Relevant 3. EEG Rationale Relevancy Your Answer There is no indication that this would be a relevant assessment at this time. Irrelevant Irrelevant 4. MRI Rationale Relevancy Your Answer There is no indication that this would be a relevant assessment at this time. Irrelevant Irrelevant 5. CAT Scan Rationale Relevancy Your Answer There is no indication that this would be a relevant assessment at this time. Irrelevant Irrelevant 6. CXR (Chest X-Ray) Rationale Relevancy Your Answer Not of value when diagnosing or treating drug addiction. Irrelevant Irrelevant Copyright @2017 by FA Davis Ryan Rodriguez | Clustering Assessment Data | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. When you are finished reviewing, click "Continue" to proceed to next section. 1. Cluster A Rationale Correct Answer Your Answer Ryan easily becomes Ryan easily becomes agitated and at times agitated and at times displays signs of displays signs of aggression: clenching his aggression: clenching his fists as well as making fists as well as making threatening comments to threatening comments to other patients and staff other patients and staff members. members. Ryan and a co-patient had Ryan and a co-patient had plans to start an plans to start an altercation with a visitor altercation with a visitor to the unit, stating that to the unit, stating that they would teach him a they would teach him a lesson. lesson. Ryan becomes agitated Ryan becomes agitated very rapidly and this very rapidly and this progresses to aggression. progresses to aggression. Ryan’s agitation and Ryan’s agitation and aggression improves aggression improves following the following the Rationale: Individuals administration of prn medication. administration of prn medication. withdrawing from drugs Ryan sought out his Ryan sought out his often experience nurse, identifying that he nurse, identifying that he increasing agitation and is becoming more is becoming more aggression. agitated and requesting agitated and requesting prn medication. prn medication. 2. Cluster B Rationale Correct Answer Your Answer Rationale: Suicidal Ryan became agitated Ryan became agitated threats need to be shortly after admission, shortly after admission, considered seriously and threatening suicide if he threatening suicide if he a suicide assessment was sent back to jail. was sent back to jail. completed. Ryan became agitated and aggressive toward Ryan became agitated and aggressive toward others and made threats others and made threats of harming himself when of harming himself when security intervened. Ryan stated he does not know what will happen to him if he is discharged as he cannot return to his father’s house and there is a warrant for his arrest. Ryan became very tearful, stating that he is afraid his mother is dying of cancer; however, he has been unable to discuss it with her. security intervened. Ryan stated he does not know what will happen to him if he is discharged as he cannot return to his father’s house and there is a warrant for his arrest. Ryan became very tearful, stating that he is afraid his mother is dying of cancer; however, he has been unable to discuss it with her. 3. Cluster C Rationale Correct Answer Your Answer Rationale: Clients with a long history of drug abuse and addiction are often reluctant to go into treatment, especially if they have not been successful in the past. Ryan states that he cannot think about treatment for his addiction at the present time. He has been in treatment before and was unsuccessful at maintaining his sobriety. Ryan began using drugs at age 13 after observing his parents smoking marijuana. Ryan states that he has a long history of substance abuse. He has used cocaine and ecstasy in the past. Recently, he was using fentanyl and meth. Ryan states that he cannot imagine a life where he doesn’t use. It’s not that big a deal. All his friends use as well. Ryan states that he cannot think about treatment for his addiction at the present time. He has been in treatment before and was unsuccessful at maintaining his sobriety. Ryan began using drugs at age 13 after observing his parents smoking marijuana. Ryan states that he has a long history of substance abuse. He has used cocaine and ecstasy in the past. Recently, he was using fentanyl and meth. Ryan states that he cannot imagine a life where he doesn’t use. It’s not that big a deal. All his friends use as well. Copyright @2017 by FA Davis Ryan Rodriguez | Assign Diagnoses | Review Back Continue Answers and Rationale Your responses are displayed below. When you are finished reviewing, click "Continue" to proceed to next section. 1. Cluster A Rationale Correct Answer Your Answer True Risk for Injury Risk for Injury 2. Cluster B Rationale Correct Answer Your Answer True Ineffective Coping Ineffective Coping 3. Cluster C Rationale Correct Answer Your Answer True Ineffective Denial Ineffective Denial Copyright @2017 by FA Davis Ryan Rodriguez | Nursing Outcomes / Individualized Goals | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. 1. The client’s condition will stabilize within 3 days. Rationale Relevancy Your Answer Rationale: It is important to successfully manage withdrawal symptoms during the acute detoxification period. Risk for Injury Risk for Injury 2. The client will not experience any physical injury. Rationale Relevancy Your Answer Rationale: A client who is in withdrawal may harm himself or others if he becomes agitated or aggressive. Risk for Injury Risk for Injury 3. The client will begin to verbalize adaptive coping mechanisms rather than abusing substances or making suicidal threats when stressed. Rationale Relevancy Your Answer Rationale: Verbalizing adaptive coping strategies is the first step in utilizing those strategies successfully. Ineffective Coping Ineffective Coping 4. The client will express his feelings related to his drug abuse and the stressors in his life. Rationale Relevancy Your Answer Rationale: Expression of feelings related to his stressors can assist the client in developing problem-solving strategies. Ineffective Coping Ineffective Coping 5. The client will begin to identify the negative impact of addictions on his life. Rationale Relevancy Your Answer Rationale: The initial step in addressing denial is identification of the relationship between addiction and the client’s personal problems. Ineffective Denial Ineffective Denial 6. The client will assume responsibility for his choices and will identify a plan to accept support and treatment. Rationale Relevancy Your Answer Rationale: In order for treatment programs to be successful, clients with addiction issues need to independently choose to attend available treatment and support programs. Ineffective Denial Ineffective Denial Copyright @2017 by FA Davis Ryan Rodriguez | Nursing Interventions / Activities | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. 1. Discuss effective coping strategies with the client. Rationale Relevancy Your Answer Rationale: The client may resort to addictive behaviors in order to deal with stress. Ineffective Coping Ineffective Coping 2. Encourage client to verbalize feelings. Rationale Relevancy Your Answer Rationale: Verbalization of feelings in a safe environment can assist the client in dealing with current stressors and unresolved issues. Ineffective Coping Ineffective Coping 3. Monitor client behavior frequently; provide prn medication when the client’s level of agitation and aggression increases. Rationale Relevancy Your Answer Rationale: Client safety is a priority. Providing medication when the client’s level of agitation increases can assist with maintaining a safe environment for the client and others. Risk for Injury Risk for Injury 4. Encourage participation in group activities. Rationale Relevancy Your Answer Rationale: Peer feedback in an important element when dealing with addictive behavior. Ineffective Denial Ineffective Coping 5. Provide positive feedback when the client demonstrates insight and accepts responsibility for his problems. Rationale Relevancy Your Answer Rationale: Positive feedback enhances the client’s self- esteem and the belief that he can successfully deal with the problems in his life. Ineffective Denial Risk for Injury 6. Monitor vital signs, especially heart rate and blood pressure. Rationale Relevancy Your Answer Rationale: Vital sign assessment is an integral part of any nursing assessment and can often be an indicator of impending or present health issues. Risk for Injury Risk for Injury 7. Encourage client use of independent problem-solving skills. Rationale Relevancy Your Answer Rationale: Promotes independence and client ownership of problems in his life. Ineffective Coping Ineffective Coping 8. Identify the current crisis situations in the client’s life and how his substance abuse contributed to those crises. Rationale Relevancy Your Answer Rationale: It is important for the client to recognize the relationship between his substance abuse and his personal problems. Ineffective Denial Ineffective Coping 9. Obtain a drug history to determine substances used, substance abuse pattern and history, and time of last ingestion. Rationale Relevancy Your Answer Rationale: An accurate drug history is essential in order to address withdrawal symptoms. Risk for Injury Risk for Injury Copyright @2017 by FA Davis