Exam (elaborations) Hesi a2 critical thinking latest update.

1. The Patient: A 65-year- old male. The Situation: The family brings the patient to the emergency room because he just took an entire bottle of pills. The Question: What action should the nurse take first? Answer – Determine the patient’s level of consciousness. 2. The Patient: An 80 year-old male who has used continuous oxygen for the past three years. The Situation: While making a home visit, the wife tells the nurse that her husband was doing well on 2 litres of oxygen per minute until late last night when he developed severe shortness of breath on the way to the bathroom. The Question: What action should the nurse take first? Answer – Assess the patient’s oxygen saturation by pulse oximeter. 3. The Patient: A 41-year-old male. The Situation: The patient is complaining of severe stomach pain and states that he has been “vomiting all the time.” The Question: What should the nurse do first? Answer – Administer a prescribed pain medication. 4. The Patient: The wife of a wealthy owner of the town’s bank. The Situation: The patient and her husband arrive on the unit. While orienting the patient to the hospital room, the nurse notices that the patient has placed a large amount of cash and some expensive earrings in the drawer of the bedside table. The Question: What is the best action for the nurse to take? Answer – Advise the patient to have her husband take the items home when he leaves. 5. The Patient: A 45-year-old female who is 5’ 2” tall, weighs 200 pounds, and has smoked since age 21. The Situation: The patient comes to the clinic with a complaint of “leg pain.” The Question: It is most important for the nurse to obtain information about which previous occurrence? Answer – A previous blood clot in the leg. 6. The Patient: A 61-year-old female. The Situation: The patient has a fever of unknown origin. The nurse administered a fever-reducing medication 30 minutes ago. At this time there has been no decrease in the patient’s fever. The Question: What action would be best for the nurse to take? Answer – Sponge the patient with cool water. 7. The Patient: A 70-year-old male who is relatively healthy. The Situation: A liquid mediation is prescribed for this patient. The Question: Prior to administering the prescribed medication, what intervention has the highest priority? Answer – Determine if the patient is allergic to the medication. 8. The Patient: A fifty-eight-year-old female. The Situation: While the nurse is offering the patient her morning medications, she tells the nurse that she does not recall ever taking a pill that was pink-colored. The Question: What should the nurse do in response to this patient’s comment? Answer – Withhold the mediation until the patient’s prescription is verify. 9. The Patients: 1. A 63-year-old with a burn on the left lower leg who is complaining of pain. 2. A 45-year-old with pneumonia, complaining of shortness of breath. 3. A 31-year-old with abdominal pain who has just vomited blood. 4. An 88-year-old who has right-sided paralysis and wants to be helped to the bathroom immediately. The Situation: The nurse is caring for these patients. The Question: Who should the nurse see first? Answer – The 45-years old with pneumonia and shortness of breath. 10. The Patients: 1. A 13-year-old female with a kidney infection who reports that there is “lots of blood” in her urine. 2. An 18-year-old male with acute alcohol poisoning who is seeing “bugs on the walls.” 3. A 21-year-old female with inflammatory bowel disease who has soaked a dressing three hours after surgery. 4. A 25-year old male who is sobbing in his room after being told that he has testicular cancer. The Situation: The nurse is caring for these four patients. The Question: Who should the nurse see first? Answer – The 21-years old who is three hours postoperative and has a soaked dressing. 11. The Patients: 1. A 42-year-old with diabetes who is blind and is asking to get up and moved to a chair. 2. An 88-year-old with lower body paralysis who wants to be turned in bed. 3. A 17-year-old with asthma who smokes and has been in the bathroom for 30 minutes. 4. A 55-year-old with cardiac disease who tells the nurse, “Get the TV fixed or I am leaving this place.” The Situation: The nurse is caring for these four patients. The Question: Which patient should the nurse see first? Answer – The 17-year old with asthma who may be smoking in the bathroom. 12. The Patient: An elderly female accompanied by her middle-aged son. The Situation: The patient is being discharged after 15-day stay on the medical unit, and the son offers the nurse a box of candy as a gesture of thanks for caring for his mother. The Question: What should the nurse do in response to the offer of this gift? Answer – Sincerely thank the son, and share the candy with all staff member on the unit. 13. The Patient: A 25-year-old female who has smoked since age 12. The Situation: The patient is complaining of “skipped heart beats.” The Question: Which instruction is most important for the nurse to provide this patient? Answer – Call for assistance if she feels weak or dizzy when getting out of bed. 14. The Patient: A frail 88-year-old male who has recently become slightly confused. The Situation: The nurse is making a home visit and assesses the safety features of the home environment. The Question: Which suggestion would be most important for the nurse to provide the family? Answer – Eliminate any throw rugs from floor. 15. The Patient: A 55-year-old female with a family history of hypertension. The Situation: The patient is concerned about her health and states, “I have had severe headaches for the last six months. I think I might have high blood pressure.” The nurse determines that the woman’s blood pressure is 138/86 (high normal).