37TH CASE SCENARIO. (NURSING)FOUND DOWN BY DAUGHTER.

Age/Sex 56years.male.

Unit Q000000015. MR Q000098944.Attending doctor Dr. DON’T HATE. CODE STATUS Full code.

Found down by daughter, Seizures, Cough, Etoh withdraw.

Secondary Diagnosis Hypertension, seizures disorder and diabetes.

Family history of hypertension and high cholesterol. Blood AC and HS.

CIWA Protocols.

Ativan 2mg IV Q8hrs.

Ativan 1mg po Q4hours prn agitation.

Room Air

Lungs clear.

Cardiac health diet.

Ambulate with assistance using the front wheel walker.

Right Saline lock.

Keppra 1000mg po Bid.

EEG negative.

Catapress 0.1mg po daily.

Lab values.

WBC = 4.6mm

H/H 11.7g/ dl

35.0 %

K 3.8mEqkcl

NA. 142.mEqkcl

PLAN .

Discharge to SNF when bed is available.

Questions:

(1)A man is hospitalized for alcohol abuse. He comes to the nursing station and ask the nurse if he can go to the Cafeteria to get something to eat. When told that his privileges does not include visiting Cafeteria, the patient became verbally abusive. What will be the most appropriate response by the nurse?

Answer:

(A)Calmly and firmly escort patient to his room.

(B) Let him go to the Cafeteria.

(C) Call the Psychiatric unit and speak to his doctor.

(D) Notify the Charge Nurse.

Correct answer is A.

(2) A client is admitted through the Emergency room to Trauma unit with a gunshot wound in the chest. History of Etoh,diabetes and Hypertension. He is in Severe respiratory distress. Which nursing action has the highest priority when managing the emergency.

Answer:

(A)Establish and maintain an open airway.

(B)Check for nose bleeding.

(C )Check to see if patient is hungry.

(D) All of the above.

Correct answer is A.

Rationale establishment of airway patency of should be the top most priority. Patient is already in a severe respiratory distress.

(3)What is CIWA Protocol?.

(A)Clinical institute withdrawal assessment for alcohol.

B Community inpatient withdrawal admission.

C Not sure of this.

D All of the above.

Correct answer A

(4) Why is this patient on CIWA Protocols?.

(A)Patient has history of alcohol abuse and withdrawing.

(B) He has a gunshot wound.

(C )He is in respiratory distress.

(D) All of the above.

(5) Did the nurse violate patient’s right when she did not allow him to go to the Cafeteria?.

5b If yes explain why.