Develop a care plan for Mrs Crisp (discussed in the case study) for her stay in critical care. Ensure that you include routine cares as well as care specifically targeted at organ support. Discuss your plan with an experienced colleague
What will be an ideal response?
Suggested response: Full health assessment performed on shift commencement and focused assessment during care. FAST-HUGS, family support and psychological care maintained. Consider obstetric review, mother–baby bonding, express breast milk if able though check for medication interactions.
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The nurse assessing an 11-year-old who is having an asthma attack expects to hear adventitious sounds of:
a. friction rub. b. sibilant wheezes. c. crackles. d. sonorous wheezes.
A client with anorexia nervosa being treated on an outpatient basis has begun refeeding. Between the
first and second appointments the nurse assesses that the client has gained 8 pounds. The nurse should a. praise the client for the weight gain. b. assess lung sounds and extremities. c. suggest use of an exercise program. d. establish a higher target for weight gain for the next week.
The client has just been diagnosed with acute respiratory distress syndrome (ARDS). The nurse is aware that both acute lung injury (ALI) and ARDS clients will often require:
1. Mechanical ventilation. 2. Frequent suctioning. 3. Frequent ice chips. 4. A living will.
A patient who has been prescribed flucytosine (Ancobon) reports reduced sensation in the fingers and toes. What is the nurse's best action?
a. Document the report as the only action. b. Hold the dose and notify the prescriber. c. Remind the patient to continue the drug as usual and to take a multiple vitamin daily. d. Reassure the patient that this is an expected drug side effect and to use injury precautions.