An older patient is hospitalized for an exacerbation of chronic obstructive pulmonary disease (COPD), for which the patient is on chronic steroid use
The patient also has a fresh dog bite on the arm, which is not reddened, swollen, and only slightly tender. The patient is afebrile, but the nurse finds the patient confused and agitated. What action by the nurse is most appropriate?
a. Place the patient on fall precautions.
b. Put a bed alarm on the patient's bed.
c. Call the rapid response team.
d. Perform a sepsis screening exam.
D
Older adults have an age-related decrease in immune function, plus this patient is on medication that diminished immune responsiveness. With the fresh wound, the nurse would be concerned about sepsis. The patient may be septic without showing local or systemic signs of infection other than confusion. Fall precautions and bed alarms may be necessary. The rapid response team is not needed.
You might also like to view...
A nurse caring for a patient that has an immunosuppressive disorder knows that continual monitoring of the patient is critical. What is the rationale behind the need for continual monitoring?
A) So the patient's needs can be met immediately B) So medications can be given as ordered and signs of adverse reactions noted C) So early signs of impending infection can be detected and treated D) So the nurse's charting can be complete and accurate
Which applications might be useful for recording reflective student clinical journals? (Select all that apply.)
a. Microsoft Word b. Microsoft Excel c. Twitter d. Blackboard
A patient becomes flaccid with fixed and dilated pupils. The patient's ICP falls from 65 to 12 mm Hg. What should the nurse suspect is happening?
a. The patient is having a seizure. b. The patient's brain has herniated. c. The patient's cerebral edema is resolving. d. The patient is excessively dehydrated from the mannitol.
When practicing effective and correct communication, the nurse should (Select all that apply.)
a. speak in a clear voice. b. be concise when providing client education. c. be concrete when communicating with clients. d. focus entirely on abstract communication techniques with clients. e. ensure that communication with clients is complete. f. provide courteous communication when interacting with clients.