Hesi Case Study – Idiopathic Scoliosis – Flashcards
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Following the meeting with the healthcare provider, what priority intervention should the nurse implement to ensure that Anthony and his family understand the information?
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Provide a review for clarification of the infromation provided
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Anthony is having diagnostic tests to confirm the diagnosis of scoliosis. Which test is the most conclusive of the diagnosis?
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An Xray
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The nurse performs an assessment on Anthony. What objective data is consistent with the diagnosis of scoliosis?
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Rib hump when bending over - hump in the area of the scapula is apparent
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To assist the nurse in learning more about the family members, what action should the nurse impelement
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Prepare a genogram and an ecomap of the family - provides the nurse global view of all family members and any role that genetics might play in their health status
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After a thorough examination, it is determined that Anthony has a spine curvature of 48 degrees. Based onthis finding, what does the nurse anticipate the healthcare provider will recommend for Anthony?
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Have surgery for realignment with internal fixation and intrumentation - surgery is indicated
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Anthony is an adolescent and according to Piaget, he is in the stage of formal operational thought. What is the best way for the nurse to teach Anthony about his surgery?
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Provide verbal and written info about the surgical treatment
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He appears upset by the dx and states that he does not want to have surgery. What action should the nurse take?
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Ask him to discuss his concerns& fears - will help the nurse provide factual info
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He is admitted to the surgery unit. In anticipation of blood loss during surgery, which intervention is most important?
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Collect blood for an autologous blood transfusion - best way to replace losses during the surgery & alleviate complications related to potential transfusion reactions
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In developing the nursing plan of care, what is the most important action to promote Anthony's participation?
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Demonstrate the use of PCA pump - will help to reassure him and will also involve him in his own care
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the nurse is aware of common post op complications. After establishing priorities, what action should the nurse implement for early detection of hypoventilation in the post op period
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Place pulse ox to monitor blood oxygen
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Possible neurovascular problem?
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Tingling in the feet - problem possibly related to the presence of a thrombus or damage to the peripheral nerve.
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While implementing the postop plan of care, the nurse checks sensation and mobility of Anthony's legs every two hours. Which nursing diagnosis does thei intervention best fit
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Potential for injury, related to presence of instrumentation system - can provoke neurovascular damage, thrombus, and even paralysis. sensation and mobility of legs must be checked regularly
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He has a PCA pump for pain control; mother doesnt want him to be addicted to pain meds. What should nurse response be?
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the pump has a set amt of meds to be delivered at a set time. There is no danger in overmedicating and the pain relief will be more immediate - facilitates a more rapid recovery
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What is th ebest assesment for the nurse to use to assess pain in an adolescent
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Visual Analog Scale - best way for an adolescent
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Which action by the nursing student would the RN question
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Measuring his urinary output every 8 hour - The I/O should be measured every 2 - 4 hours to monitor for signs of fluid overload or SIADH, a common complication of scoliosis surgery
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Part of Anthonys pos op care is to wear a brace. What nursing dx is related to the wearing of a brace
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Alteration of body image, related to the wearing of a brace - evokes negative self-image in a teen
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Which med would the nurse anticipate the hcp Rx to him?
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Docusate - bc of immobility and increased use of opioid pain meds, prevention of constipation is a priority
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Before leaving the hospital, Anthonys mother asks the nurse which activities are approp. for him?
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Anthony may participate in swimming or cycling after four mounths
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Discharge instructions related to wearing a brace at home
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Always wear a tshirt under the brace - wear light clothing under the brace in order to promote comfort and prevent skin irritations
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What instructions should be included in Anthonys discharge planning
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he should follow up with the hcp on a regularly scheduled basis = important for good recovery & should advocate for compliance with follow up
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What nursing action best promotes family centered care after Anthony returns home?
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Teach family members about care related to the wearing of a brace - to promote proper usage
