Mrs Thelma Jacobs

Question 1

Her husband states she is having difficulty speaking, seems confused and 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?

Answer 1

Glasgow Coma Score

Question 2

In the ABCDE of initial assessment and treatment in acute situations, the ‘D’ refers to:

Answer 2

Disability

Question 3

Damage to which area of the brain is likely to have resulted in Thelma’s symptoms? 
Broca’s area 
Occipital lobe 
Frontal lobe 
Primary somatosensory area 
Premotor area

Answer 3

Broca’s area and Frontal lobe

Question 4

Identify an appropriate nursing diagnosis for Thelma

Answer 4

Falls risk r/t confused state and right sided weakness

Question 5

An appropriate SMART goal for Thelma is?

Answer 5

“For Thelma to have a pain score of < 1 by the end of todays shift”

Needs to have a _ underneath the < but idk how to do that

Question 6

Identify the correct nursing intervention for Thelma.
Perform 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.

Answer 6

All of the above

Question 7

What critical thinking skill helps you to see relationships among the data?

Answer 7

Clustering related cues