Question

Please answer all the question that go with the scenario will thumbs up for correct answer.You are the RN caring for Mrs. M.T., a 72 year old female patient who is admitted for a UTI. M.T. has a history of UTIs, urinary retention,HTN, hyperlipidemia, asthma, glaucoma, and a left femoral-popliteal bypass. (#11-20)

16. Due to M.T.’s history of glaucoma, you know that she may experience which of the following?

a.Loss of peripheral vision

b. Loss of central vision

c.A cloudy appearance on her eyes

d. Double vision

17. While assessing M.T’s peripheral pulses, you are unable to find a pedal pulse on the left side via

palpation or Doppler. What is your next nursing action?

a.Contact the MD immediately

b. Attempt to locate left a femoral pulse

c.No action is needed, this is a normal finding for someone with a history of a left femoral-popliteal bypass

d. Attempt to locate a left posterior tibial pulse

If you are unable to find a pedal pulse, what other assessments can you do to determine if M.T.

is perfusing to her left foot? (List at least three)

______________________________________________________________________________

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19. While performing the abdominal assessment, M.T. complains of sharp pain to her right lower

quadrant. What do you suspect could be the cause? And what bedside exams can you as the RN

do to help you determine the cause of the pain?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

20. After you finish M.T.’s admission assessment, you determine M.T. to be a fall risk. Describe the

patient education you will give to this patient.

Answer 1

16. a. loss of peripheral vision

In glaucoma in the early stage peripheral vision loss may occur, In later stages central vision loss may also occur

17. contact M.D immediately. If unable to find peripheral pulses means another way to find the circulation of the legs are

Assess for the colour ( pink or pale or black)

check for the warmth ( hot or cool)

check for sensations ( able to feel the pain, touch)

assess for ability to movement

19. Right lower quadrant pain sharp in nature may suggestive of appendicitis.

Signs of appendicitis which helps to determine the cause are

Mc Burney sign- Localized rebound tenderness in the Mc burney's point

Rovsing sign- pain to the right lower quadrant while palpating the left lower quadrant.

20. Patient education for risk for fall

• Keep raise the side rails of the bed
• while walk or move out of bed careful.
• Ask for assistance when ever need to get out of bed.
• use non slippery footwear
• After waking from bed, sit for few minutes, then try to move while feel giddiness not try to move.
• Ensure the bed is locked while getting out of bed.
• Keep lights on, while night time use night light.
• Know your ability to move, if cannot to move, ask for help.