Tell a Nurse Chapters 1-20

Question 1

What are things to notice that might suggest Delirium to a patient that is normally alert and oriented?

Answer 1

• Person is hallucinating something you know cannot be possibly true.
• Person does not recognize someone familiar or mistakes a stranger for a family member or close friend.
• Person is very restless especially at night
• Person seems confused
• Person talks frequently about events from the past but cannot remember events that occurred recently.
• Person gets lost or wanders the halls aimlessly even though they know the layout of the building

Question 2

What are the possible signs of infection?

Answer 2

• Increase in body temperature (elderly people may only have slight increase or no increase)
• Rapid pulse, rapid respiratory or changes in blood pressure
• Pain, coughing or difficulty in breathing
• Redness. swelling or pain
• Foul smelling or cloudy urine
• Pain or difficulty urinating
• Diarrhea or foul smelling feces
• Nausea or vomiting
• Lack of appetite
• Skin rashes,
• Fatigue
• Increased confusion or disorientation
• Any unusual discharge or drainage from the body.

Question 3

What do you look out for when a patient has restraints on?

Answer 3

• Complains of or shows any signs of shortness of breath or difficulty of breathing
• Hand or foot beyond the restraint is pale, blue, cold
• Complains of pain, numbness, tingling at or below a restrained body part
• Skin beneath is red, blistered, broken or bruised.
• Patient becomes more confused or disoriented or agitated.

Question 4

What are the signs or symptoms to look over in immobility?

Answer 4

• Redden skin especially over the bony areas that does not return to normal color after gentle massage of the surrounding tissue
• Pale, white or shiny skin over a bony area
• Tears, scrapes, skin that looked burned
• Hot, redden, painful areas in the lower legs ( DO NOT Rub the area)
• New occurrence of urinary or bowl incontinence
• New complaints of pain on movement
• Any disconnected or heavily draining tubes or drains

Question 5

What do you look for when transferring a patient?

Answer 5

• Complains of dizziness, shortness of breath, chest pain, rapid heartbeat or sudden head pain
• Complains of pain when they try to bear weight and this is new
• Observe any changes in the person’s usual grip, strength or ability
• Usually cooperative person refusing to participate
• The equipment not working properly or broken

Question 6

What do you look out / know for when a person faints?

Answer 6

• What time
• Whether there was a change in consciousness and if so how long
• Whether the person vomited
• The person’s appearance at the time of the fainting
• Whether the person complained of anything before the incident (loss of vision, dizziness or nausea)
• The actions you took to assist the person

Question 7

What observations do you report to the nurse regarding a patient’s room.

Answer 7

• Notice that a piece of equipment or furniture in the room is not working properly
• A patient or resident has been injured by a piece of equipment or furniture in the room
• You have been injured by a piece of equipment
• You suspect that the patient is storing unwrapped food in the drawer or closet
• Patient’s family complains that a personal item are missing
• You accidentally break a personal item belonging to the patient
• Bathroom fixtures and floors do not appear to be properly cleaned or wastebaskets are not emptied
• There is an odor in the room that cannot be eliminated
• Environmental factors are affecting the patient or resident’s ability to function independently

Question 8

What do you look for when a patient is discharging or transferring to another facility or place.

Answer 8

• Any questions that have to do with person’s medical condition or transfer
• Any comments that would indicate that the person or family member does not fully understand what they have been told
• Any signs of anxiety like crying, confusion, agitation, or unexplained behavior
• Any changes in the person’s vital signs or mental status
• Any mention of leaving against the facility medical advice (AMA)

Question 9

What to look out for when taking a temperature?

Answer 9

• The person’s temperature is higher than normal
• The person’s temperature is lower than normal
• You have difficulty talking and reading the person’s temperature

Question 10

What to look out for when taking a pulse?

Answer 10

• Person’s pulse is higher than normal
• Person’s pulse is lower than normal
• Pulse is irregular
• Pulse is weak or thready
• Have difficulty with taking the pulse.

Question 11

What to look out for when taking respirations?

Answer 11

• Respiratory rate is greater than 24 breaths per minute
• Respiratory rate is less than 10 breaths
• Respiratory rhythm is irregular
• Person’s breaths are very deep or very shallow
• Person’s breathing is difficult or painful
• Person’s chest does not rise equally on both sides
• Person’s respirations are noisy with wheezing sounds or congestion

Question 12

What to look out for when taking blood pressure?

Answer 12

• Person’s blood pressure is higher than normal
• Person’s blood pressure is lower than normal
• Difficulty measuring the blood pressure