Tell a Nurse Chapters 20-40

Question 1

What to look out for when a person is being treated with CPAP Therapy?

Answer 1

• Person refuses to put on the mask or takes it off
• Hissing noise coming from or around the seal of the mask or tubing
• CPAP machine is not working properly
• Mask or straps are causing irritation of the person’s skin

Question 2

What to look for when a its nighttime and patients are sleeping

Answer 2

• Person is awake frequently during the night
• Person lies awake for periods of long time before falling asleep again
• Person report wakefulness or difficulty sleeping
• Person seems sleepily during the day
• Person gets up frequently during the night to urinate
• Person tells or shows discomfort or signs of pain
• Person reports inability to sleep or stay asleep as a result of the environment
• Person expresses worry or anxiety about something.

Question 3

What to look for when assisting a person with Oral Care?

Answer 3

• Dry, red, cracked or bleeding lips , gums, mucous membranes
• Cold sores on lips or mucous membrane
• Red. irritated, swollen, or bleeding gums
• Cracked, chipped teeth, loose teeth or blackened teeth
• Chipped, cracked or poorly fitting dentures
• Red sores or canker sores inside the mouth, white spots, or signs of pus or infection
• Bad breath that does not improve after oral care
• Fruity smelling breath (possibly of diabetes)
• Red or swollen tongue or white coating on the tongue
• Complaints of pain or sensitivity.

Question 4

What to out for when observing for skin breakdowns?

Answer 4

• Reddened skin especially over bony areas
• Pale, white or shiny skin over a bony area
• Areas of skin that are hot to the touch
• Areas of skin that is painful or tender

Question 5

While providing foot care or hand care, what do you need to look for regarding infections or illness?

Answer 5

• Nail beds are either very pale or blue or bruised
• Nails that are unusually yellow or white
• Nails that are unusually thick
• Nails that are broken or have been cut too short
• Nails that are overgrown
• Cuticles that are torn, red, swollen
• Skin that is blistered, red or tender
• Any unusual rashes or odors

Question 6

While providing hair care, what do you need to look for?

Answer 6

• Flaking, crusting, scaling of the scalp
• Redness, itching, tenderness of the scalp
• Unusual hair loss especially if it is occurring in patches
• A foul smell
• Severely matted or tangled hair
• Nits

Question 7

What to look for when a collecting urine?

Answer 7

• Is cloudy or contain particles. has abnormal color or odor
• Complains that urine is difficult or painful to pass (if the person has dysuria)
• Experiencing frequency, urgency, or both
• Person needs to get up more frequently than usual to use the bathroom during the night
• Person having incontinence accidents or more frequent incontinence accidents

Question 7

What to look for when a person has enteral nutrition and might be chocking?

Answer 7

– Nausea or bloating or pain during feeding

• Coughing, gagging or vomiting during the feeding
• Abdominal distention
• Drainage from around the tube insertion site
• Disconnected tubing

Question 8

What to look for when providing catheter care?

Answer 8

• Changes in color, clarity, odor or the urine
• Failure to urine to flow freely through the tubing
• Person is complains of pain or discomfort as a result of catheter
• Redness, swelling, or discharge from the catheter insertion site
• Leaking of urine around the catheter insertion site

Question 9

What to look for when assisting with a Bedpan?

Answer 9

• Person has diarrhea or constipated
• Blood or mucus in the stool
• Stool is black or dark green
• Stool is foul smelling
• Person complains of that the feces are painful or difficult to pass
• There is bleeding from the anus during or after bowl movement
• Person has swollen abdomen or complains of abdominal pain
• Person complains of liquid feces seeping from the anus
• Person has excessive flatus (gas)

Question 10

What to look for when a person is terminally ill ?

Answer 10

• Person refuses medications or other medical treatment
• Person cries constantly, refuses food, or cannot sleep
• There is tension and disagreement within the family
• The person or family member request the assistance of a religious leader or grief counselor
• Person expresses interest in making or changing legal documents related to end of life care

Question 11

What to look for when a person is dying?

Answer 11

• Person seems to be in pain
• Trouble breathing
• Asks to see a religious leader
• Overwhelmed by the number of visitors or the length of time they are staying
• Family member has a question about the person’s care or condition that you are not qualified to answer
• The person has died

Question 12

What to look for when doing skin care?

Answer 12

• Skin looks abnormally pale or flushed or has a bluish or yellowish hue
• The person has a new rash, or changes in an existing rash
• The person has a mole that has changed in appearance

Question 13

What should you look out for when caring for pressure ulcers?

Answer 13

• Person has paleness or redness over a pressure point that does not go away within 5 minutes
• Area over a pressure point that was previously red has become pale, white, shiny
• Area over a pressure point that was previously red is hot to the touch or painful
• A pressure ulcer has changed in size or depth

Question 14

What should you look for when caring for wounds?

Answer 14

• A person complains of increased pain or discomfort
• Increased in redness, swelling or warmth around the wound
• The person has a fever
• Drainage from the wound has changed in amount or appearance or has developed a foul odor
• The dressing is excessively wet or soiled
• the drain tubing has pulled out or has become disconnected
• The V.A.C ATS therapy System is not functioning properly

Question 15

What should you look for when caring for musculoskeletal system?

Answer 15

• The person has fallen
• Area has become swollen, red, bruised tender or painful to the touch
• Person complains of pain when moving a joint
• Person has usual range of motion of a joint has decreased
• Person limps or has pain while walking or makes excuses to avoid walking
• Person guards or rubs a joint even when not moving

-Person has decreased muscle strength

Question 16

What should you look for when caring for the respiratory system?

Answer 16

• Person experiences the sudden onset of chest pain or difficulty breathing
• Person develops noisy breathing (wheezing or barking or crowing)
• Person begins to make a fluid like gurgling sounds
• Oxygen flow rate on the flow meter does not match the ordered amount of oxygen
• Gauge on the pressurized oxygen tank indicates that the oxygen level is low
• The screen on pulse oximeter shows a reading less than 90%
• A person’s skin has a blue or gray tinged either at rest or while exercising
• Person coughs up sputum that is discolored (green, frothy, brown or red streaked)
• Person’s tracheostomy or endotracheal tube becomes dislodged
• A person becomes short of breath during physical activity that they have performed without effort in the past.
• Person respirations become very slow and shallow or they stop

Question 17

What should you look out for when doing vital signs on the cardiovascular system?

Answer 17

• Complaints of chest pain or pressure
• Labored or difficult breathing
• Rapid or erratic pulse
• Slow or weak pulse
• Blood pressure reading that either much higher or much lower than the person’s usual reading
• Cyanosis of the face, lips, or fingers
• Decreased tolerance for usual exertion
• Red, painful or swollen areas in the extremities especially the calves of the legs
• Unusual swelling of the legs especially if it is accompanied by red, shiny skin
• “Dusky” (blue or grayish) coloring of the legs especially if it is accompanied by a diminished pulse and coldness of the skin

Question 18

What should you look out for when caring for someone with diabetes?

Answer 18

• Person has signs or symptoms of hypoglycemia or hyperglycemia
• Person refuses a meal or snack or only eats part of it
• Person has vomited
• The person has received gifts of food from visitors
• The person is taking food from others
• The person activity level has changed significantly (either less or more)

Question 19

What should you look for in the urinary system?

Answer 19

• Complaints of sharp, sudden pain of the abdomen, side or back
• Blood in the urine
• Significant increase or decrease in the amount of urine voided in a period of time
• Changes in a person’s voiding habit, especially increased or decreased frequency or a new onset of incontinence
• Pain or burning when urinating
• Urine that appears cloudy or has a strong ammonia smell
• Increased in confusion, decreased alertness or unusual behavior especially in older people.

Question 20

What should you do when assisting female patients with hygiene and toileting?

Answer 20

• Person has an unusual vaginal discharge
• Person has vaginal bleeding but they have already gone through menopause
• Person has very heavy vaginal bleeding during their menstrual period
• Person has pain or cramping in their lower abdomen
• Person complains of a feeling of pelvic pressure or fullness
• Person complains of problems emptying their bowl or bladder
• There is protrusion from the vaginal opening
• Person reports itching or burning around the vulva
• The skin around the vulva is inflamed or irritated
• Changes in skin color, sores that do not heal lumps, unusual swelling or thickened areas around vulva
• Lump or thickened areas around vulva
• There is discharge from the nipples or puckering of the skin of the breasts.

Question 21

What should you look for when assisting a male with toileting?

Answer 21

-Person has unusual discharge from penis especially if it contains blood or discolored secretions.

• Person has pain or burning when urinating
• Lump or thickened area in the testes
• Changes in the skin surrounding the scrotum or penis
• Reddened or irritated skin in the genital area
• Person complains of pain or aching in the scrotum or rectal area.

Question 22

What should you look for when caring for rehabilitation patients?

Answer 22

• A supportive device or assistive device is broken or not working properly
• The person has a change in vital signs during or after the rehabilitation or restorative care activity
• The person has pain, swelling, redness or signs of inflammation around supportive devices or prosthetic devices
• The person is showing signs of depression or excessive frustration like crying or withdrawal anger or talk of suicide .
• Having excessive difficulty with new rehabilitation technique or treatment