The evaluation tool of reflective journaling is a process where an individual writes down their thoughts, feelings, and experiences about a particular topic or situation.
This tool allows individuals to assess their own learning and progress, and helps to identify areas where they can improve. Reflective journaling requires the individual to engage in self-reflection, which involves critically analyzing their thoughts, feelings, and behaviors. It involves writing down the challenges faced, the success achieved, and the lessons learned, and evaluating them to gain a better understanding of one's own growth and development. Through this evaluation process, individuals can identify their strengths and weaknesses, set goals for themselves, and track their progress over time.
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1. A nurse is reinforcing discharge teaching with the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first during the event of a seizure?
A. Reorient the client.
B. Protect the client's head.
C. Loosen constrictive clothing.
D. Turn the client on his side.
2. A nurse is reinforcing teaching with a group of client's about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching?
A. A TIA can cause irreversible hemiparesis.
B. A TIA can be the result of cerebral bleeding.
C. A TIA can cause cerebral edema.
D. A TIA can precede an ischemic stroke.
3. A nurse is collecting data from a client following a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?
A. Widened pulse pressure
B. Tachycardia
C. Periorbital edema
D. Decrease in urine output
4. A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the provider to which of the following information in the client's history is a contraindication to the procedure?
A. The client has a new tattoo.
B. The client is unable to sit upright.
C. The client has a history of peripheral vascular disease.
D. The client has a pacemaker
Answer:
Explanation:
1. D. Turn the client on his side.
During a seizure, the safety of the client is a priority. Turning the client on their side helps to prevent aspiration and allows for drainage of oral secretions, minimizing the risk of choking or respiratory compromise. This position also helps to maintain an open airway.
2. D. A TIA can precede an ischemic stroke.
Transient ischemic attacks (TIAs) are temporary episodes of neurological dysfunction caused by a temporary disruption of blood flow to a specific part of the brain. TIAs are often considered warning signs of an impending ischemic stroke. Prompt medical attention and intervention are necessary to prevent a subsequent stroke.
3. A. Widened pulse pressure
An increased pulse pressure (difference between systolic and diastolic blood pressure) is a manifestation of increased intracranial pressure (ICP). It occurs due to increased pressure within the cranial cavity, which can compress blood vessels and lead to an elevated systolic pressure and a decreased diastolic pressure.
4. D. The client has a pacemaker
Having a pacemaker is a contraindication to undergoing a magnetic resonance imaging (MRI) examination. MRI uses strong magnetic fields that can interfere with the functioning of the pacemaker and potentially cause harm to the client. Alternative imaging methods should be considered for clients with pacemakers.
1. protect the clients head ,2. A TIA can cause cerebral edema, 3. periorbital edema, 4. The client has a pacemaker. Nurse should identify the above conditions
1. When a client experiences a seizure, the first action that the family should take is to protect the client's head. This is important as seizures can cause the person to lose consciousness, and they may hit their head on a hard surface, which can cause serious injuries. The family should remove any nearby objects that may cause harm and cushion the client's head with a soft object such as a pillow or clothing. Once the head is protected, the family can then turn the client on their side to prevent choking, loosen constrictive clothing, and reorient the client as necessary.
2. Transient ischemic attacks (TIAs) are temporary episodes of reduced blood flow to the brain that can last from a few minutes to several hours. The nurse should teach clients that TIAs can precede an ischemic stroke, which is a more severe form of the condition. It is important to seek immediate medical attention if a TIA is suspected as it can indicate a higher risk of a stroke. The nurse should also inform clients that TIAs are not usually associated with permanent neurological deficits such as hemiparesis or cerebral edema.
3. Increased intracranial pressure (ICP) is a medical emergency that can occur after a head injury. The nurse should recognize that a widened pulse pressure, tachycardia, and a decrease in urine output are all signs of increased ICP. The periorbital edema, or swelling around the eyes, is not necessarily a manifestation of increased ICP but may indicate a head injury.
4. Magnetic resonance imaging (MRI) is a diagnostic imaging test that uses a magnetic field and radio waves to produce detailed images of the body. The nurse should alert the provider if the client has a pacemaker as it can be a contraindication to the procedure. The magnetic field can interfere with the pacemaker and cause it to malfunction. The client's history of a new tattoo, inability to sit upright, or peripheral vascular disease are not necessarily contraindications to the procedure.
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Which of the following clinical data elements is NOT usually documented in the acute-care health record? O Clinical observations O Medical history O Immunization records O Discharge summary
The clinical data element that is NOT usually documented in the acute-care health record is "Immunization records." In an acute-care setting, the primary focus is on treating immediate medical needs, so the health record typically includes clinical observations, medical history, and discharge summary. Immunization records are generally maintained in a patient's primary care or public health records.
Based on my understanding, the clinical data element that is NOT usually documented in the acute-care health record is immunization records. Acute-care health records typically include documentation of clinical observations such as vital signs, medical history, and discharge summary. However, immunization records are usually maintained separately from the acute-care health record, either by the patient or the healthcare provider responsible for administering the immunization. This is because immunization records are important for tracking an individual's vaccination history over their lifetime and are not necessarily specific to a particular acute-care episode.
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