Term
| Three days ago, a client was admitted to the medical unit for a GI bleed. His BP and pulse rate gradually increased, and he developed a low grade fever. What assessment data should the nurse obtain? What kind of anticipatory planning should the nurse develop? |
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Definition
| Obt drug and alcohol consumption assessment, including type, frequency, and time of last dose or drink. Call HCP and report findings. Anticipate withdrawal and delirium tremens. Provide a quiet, safe enviroment. place of seizure precautions. Anticipate giving a medication like Librium. |
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Term
| What physical signs might indicate that a client is abusing IV meds? |
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Definition
| Needle track marks; cellulitis at puncture site; poor nutritional status |
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Term
| What behaviors would indicate to the nurse manager that an employee has a possible substance abuse problem? |
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Definition
| Change in work performance, withdrawal, increase in absences (esp mondays and fridays), increase in number of times tardy, long breaks, lateness returning from lunch |
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Term
| A client becomes extremely agitated, abusive and very suspicious. He is currently undergoing detox from alcohol with Librium 15mg every 6 hours. What nursing actions are indicated? |
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Definition
| Notify HCP immediately and anticipate an increase in dose or frequency of librium. Provide a quiet, safe enviroment. Approach in a quiet, calm manner Avoid touching the client |
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Term
| A client in the thrid week of a cocaine rehab program returns from an unsupervised pass. the nurse notices that he is euphoric and is socializing with the other clients more than he has in the past. What nursing actions are indicated? |
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Definition
| Notify HCP of observed behavior change. Get a urine drug screen prescribed Confront client with observed behavior change. |
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Term
| What family dynamics are often seen in child abuse cases? |
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Definition
| Parent sees child as "different" from other children. Parent uses child to meet his or her own needs. Parent seldom touches or responds to child. parent may be very critical of child. There is a family hx of frequent moves, unstable employment, marital discord, and family violence. One parent answers all the questions |
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Term
| What behavior might the nurse observe in a child who is abused? |
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Definition
| Child may appear frightened and withdrawn in the presence of parent or adult |
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Term
| Identify nursing interventions for dealing with an abused child |
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Definition
| All cases of suspected abuse must be reported to appropriate local and state agencies. Take color photographs of injuries. Document factual, objective statements of childs physical condition, childs family interactions, and interviews with family. Establish trust and care for the childs physical problems. There are the primary and immediate needs of theses children. Recognize own feelings of disgust and contempt for the parents. Teach basic child development and parenting skills to family. |
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Term
| When does battering of women often begin or escalate? |
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Definition
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Term
| What dynamics prevent a battered spouse from leaving the battering situation? |
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Definition
| a woman in a battering relationship may lack self confidence and feel trapped She is often embarrassed to tell friends and family, so she becomes isolated and dependent upon the abuser |
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Term
| Why is elderly abuse so underreported? |
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Definition
| It is difficult for an elderly person to admit abuse for fear of being placed in a nursing home or being abandoned |
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Term
| What types of abuse are seen in the elderly |
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Definition
| Abuse can be physical, verbal, psychosocial, exploitive, or physical neglect |
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Term
| Identify nursing interventions for working with a rape survious? |
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Definition
| Communicate Nonjudgmental acceptance, provide physical care to treat injuries. Give clear concise explanations of all procedures to be performed. Notif police encourage victim to prosecute. Collect and label evidence carefully in the presence of a witness. Document factual objective statements about physical condition; record clients exact words in describing the assault. Notify rape crisis team or counselor if available in the community. Allow discussion of feelings about the assault. Advise of poential or vereal diseases, HIV or pregnancy and describe medical care available. |
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