Author Question: The nurse receives the following report on four patients on the medical-surgical unit. Which patient ... (Read 63 times)

Evvie72 · **on:** Jul 23, 2018

The nurse receives the following report on four patients on the medical-surgical unit. Which patient will the nurse attend to first?

a. Gait unsteady, uses walker, needs 2-person assist with ambulation
b. Abdominal wound is draining foul-smelling fluid, incision margins are red, heart rate 100 beats/min
c. Blood pressure 90/50 mm Hg, heart rate 40 beats/min, rates chest pain at 8 on a 0 to 10 pain scale
d. Verbalizes history of migraine headaches, eyes closed during assessment interview

Question 2

The nurse is working on an orthopedic unit in the local hospital.

While assessing her patient the patient states, Ever since we had the earthquake in California I can't sleep for fear of another one happening during the night, and I just keep having flashbacks of the earthquake. The nurse knows that these patient statements are most consistent with:
a. Anxiety
b. Lack of coping skills
c. Post-traumatic stress disorder
d. Crisis

flexer1n1 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

C
Unstable vital signs with chest pain is of the highest priority because these symptoms may be life threatening. These instabilities must be addressed at once. Although an unsteady gait places a patient at risk for falls, this answer indicates that the patient uses a walker and 2-person assist. The draining wound is infected; however, this can be addressed with medications. Infections do not usually progress rapidly (i.e., as compared with chest pain). The wound symptoms are not immediately life threatening. A patient with a history of migraine headaches is not a priority at this time, although the patient's pain should be relieved as quickly as possible after dealing with the highest priority problem(s).

Answer to Question 2

C
The statements by this patient are most consistent with post-traumatic stress disorder (PTSD): a specific response to a violent, traumatizing event such as a natural disaster (flood, earthquake) or physical or emotional abuse (war, rape). The victim experiences anxiety and flashbacks that may last for months or years. A crisis exists when an event in a person's life drastically changes the person's routine and he perceive it as a threat to self. Such events are usually sudden and unexpected such as a serious illness, death of a loved one, serious financial loss, and natural disaster. It is not common, however, for people in crisis to experience flashbacks. Flashbacks are most consistent with PTSD.