Mrs Thelma Jacobs Flashcards
Mrs Thelma jacobs a 72 year old female is brought in with a lowered level of consciousness (Loc) and sore right rip. She was found by her husband on the bathroom floor, her husband states she is having difficulty speaking, seems confused about was unable to stand up due to some weakness and pain in the right arm and leg. Thelma has a history of depression, high cholesterol and hypertension
- what is the most appropriate assessment for Mrs Jacobs ?
Glasgow coma scale
In the ABCDE of initial assessment and treatment in acute situations, the D refers to:
Disability
Damage to which area of the brain is likely to have resulted in thelma’s symptoms? I. Broca’s area II. Occipital lobe III. Frontal lobe IV. Primary somatosensory area V. Promoter area
Both I and III
Identify an appropriate nursing diagnosis for Thelma
Falls risk r/t confused state and right sided weakness
An are appropriate SMART goal for Thelma is?
“For Thelma to have a pain score of _<1 by the end of today’s shift”
Identify the correct nursing intervention for Thelma out of these:
- preform a pain scale as part of checking Thelma’s vital signs
- provide pressure area care every four hours or as often as needed
- withhold any food or fluids until her ability to safely swallow has been assessed by a speech language therapist
All of the above
Which critical thinking skill helps you to see relationships among the data?
Clustering related cues