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Physical assessment (NURS 190)
West Coast University
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Individual Name:
Institution:
Program Type:
Taylor Liljedahl
West Coast U Ontario BSN BSN
Standard Use Time and Score
Date/Time Time Use Score
Alcohol Use Disorder 5/14/2021 7:18:40 PM 36 min Satisfactory
Module Report
Real Life RN Mental Health 3.
Alcohol Use Disorder
Tutorial:
Module:
Reasoning Scenario Details
Alcohol Use Disorder - Use on 5/14/2021 7:17:46 PM
Reasoning Scenario Performance Related to Outcomes:
*See Score Explanation and Interpretation below for additional details.
Body Function Strong Satisfactory
Needs Improvement
Cognition and Sensation 91% 8%
Ingestion, Digestion, Absorption & Elimination 100%
Oxygenation 100%
NCLEX RN Strong Satisfactory
Needs Improvement
RN Safety and Infection Control 100%
RN Health Promotion and Maintenance 100%
RN Psychosocial Integrity 100%
RN Basic Care and Comfort 100%
RN Pharmacological and Parenteral Therapies 100%
QSEN Strong Satisfactory
Needs Improvement
Safety 100%
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Patient-Centered Care 100%
Evidence Based Practice 80% 20%
Decision Log:
Optimal Decision
Scenario Nurse Stacy completes the admission assessment of Mr. Moore.
Question Nurse Stacy is completing the admission process for Mr. Moore. Which of the following nursing assessments should Stacy complete? (Select all that apply)
Selected Ordering CAGE questionnaireFall risk assessmentBraden scaleNumeric pain scale
Rationale The CAGE questionnaire is used for all clients, especially those with a history of alcohol use disorder fall risk assessment is used for clients who have a risk factor of falling, such as those with confusion and substance use disorder Braden Scale and the numeric pain scale are used for all clients admitted to an inpatient hospital setting Hamildon Depression Scale is used for clients who have depression Braden Scale and the numeric pain scale are used for all clients admitted to an inpatient hospital setting.
Optimal Decision
Scenario Nurse Stacy completes an assessment of possible alcohol use disorder using the CAGE questionnaire.
Question Nurse Stacy plans to complete the CAGE questionnaire as part of her nursing assessment. Which of the following questions is included in this questionnaire?
Selected Option Have you ever felt bad or guilty about your drinking?
Rationale This is one of the four questions asked when administering the CAGE questionnaire.
Optimal Decision
Scenario Nurse Stacy anticipates a medication prescription for Mr. Moore, who is in acute alcohol withdrawal.
Question Nurse Stacy is caring for Mr. Moore, who is in acute alcohol withdrawal. She should anticipate the provider will prescribe which of the following medications?
Selected Option Lorazepam (Ativan)
Rationale Lorazepam is a benzodiazepine, which commonly is ised to treat acute alcohol withdrawal.
Scenario Nurse Stacy notifies Dr. Edwards of a change in Mr. Moore's condition.
Question Using the SBAR format, Nurse Stacy calls Dr. Edwards and reports her assessment findings. What should she include in her report? (Fill in the blank and click on the submit button when you finish.)
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X = 0 hr Step 5: Set up an equation and solve for X. Volume (mL)X mL/hr = &#160 Time (hr)100 mLX mL/hr = &#1600 hr X mL/hr = 300 mL/hr Step 6: Round if necessary. 300 mL/hr = 300 mL/hr Step 7: Determine whether the amount to administer makes sense. If the prescription reads 100 mL to infuse over 20 min, it makes sense to administer 300 mL/hr. The nurse should set the IV pump to deliver famotidine 20 mg in 100 mL 0% sodium chloride IV at 300 mL/hr. Follow these steps to calculate the infusion rate using the Desired Over Have method of calculation: Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 100 mL Step 3: What is the total infusion time? 20 min Step 4: Should the nurse convert the units of measurement? Yes (min does not equal hr) 20 min × 1 hrX hr = 60 min X hr = 0 hr Step 5: Set up an equation and solve for X. Volume (mL)X mL/hr = &#160Time (hr)100 mLX mL/hr/td> = &#1600 hr X mL/hr = 300 mL/hr Step 6: Round if necessary. 300 mL/hr = 300 mL/hr Step 7: Determine whether the amount to administer makes sense. If the prescription reads 100 mL to infuse over 20 min, it makes sense to administer 300 mL/hr. The nurse should set the IV pump to deliver famotidine 20 mg in 100 mL 0% sodium chloride IV at 300 mL/hr. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation: Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/hr = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 100 mLX mL/hr = &#16020 min Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 100 mL60 minX mL/hr = &#160 × &#16020 min1 hr Step 4: Solve for X. X mL/hr = 300 mL/hr Step 5: Round if necessary. Step 6: Determine whether the amount to administer makes sense. If the prescription reads 100 mL to infuse over 20 min, it makes sense to administer 300 mL/hr. The nurse should set the IV pump to deliver famotidine 20 mg in 100 mL 0% sodium chloride IV at 300 mL/hr.
Optimal Decision
Scenario Mr. Moore lacks understanding of the importance of thiamine (vitamin B1).
Question Nurse Stacy is preparing to review the importance of thiamine (vitamin B1) replacement therapy with Mr. Moore. Which of the following statements should be included in this discussion?
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Selected Option "This medication works on the nervous system to prevent encephalopathy."
Rationale A deficiency of thiamine can result in Wernicke-Korsakoff syndrome.
Optimal Decision
Scenario Mr. Moore demonstrates maladaptive coping mechanisms in interactions with hospital personnel.
Question Mr. Moore had interactions with hospital personnel earlier in the day. Which of the following videos is an example of Mr. Moore’s use of denial as a maladaptive coping mechanism? (Review each of the videos. After making your selection, click on the submit button.)
Selected Option Video|81d9169e011848a985f9785a3d9f86e
Rationale The client uses denial when he refuses to admit he has an alcohol use disorder while talking with the social worker.
Optimal Decision
Scenario Nurse Stacy offers a therapeutic response to Mr. Moore, who is using the defense mechanism of denial.
Question Mr. Moore states he does not have a problem with alcohol. Which of the following is a therapeutic response to this statement by Nurse Stacy?
Selected Option "So you don’t think you’re an alcoholic?"
Rationale This is an appropriate use of the therapeutic technique of restating.
Optimal Decision
Scenario Nurse Steve intervenes with a potentially violent Mr. Moore to de-escalate the situation.
Question Nurse Steve is caring for Mr. Moore, who is angry and is raising his voice. Which of the following is Steve’s priority intervention at this time?
Selected Option Tell Mr. Moore in a firm voice to stop his behavior.
Rationale By remaining calm and firmly telling the client to stop the behavior, the nurse can de-escalate a potentially violent situation and avoid more restrictive measures.
Optimal Decision
Scenario Nurse Steve and Social Worker Eva discuss the objective of an intensive outpatient program with Mr. Moore.
Question Nurse Steve reviews the objective of an intensive outpatient program with Mr. Moore. Which of the following is an appropriate statement by Steve?
Selected Option "In an intensive outpatient program, care will be individualized to meet your treatment needs."
Rationale Intensive outpatient programs are responsive to the specific needs of the client.
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atitesting © Assessment Technologies Institute®, Inc.
EX_RealLife_Ind
REASONING SCENARIO INFORMATION
Reasoning Scenario Information provides the date, time and amount of time use, along with the score earned for each attempt. The percentage of students earning a Scenario Performance of Strong, Satisfactory, or Needs Improvement is provided. In addition, the Scenario Performance for each student is provided, along with date, time, and time use for each attempt. This information is also provided for the Optimal Decision Mode if it has been enabled.
If a detrimental decision is made during a Real Life scenario, the scenario will diverge from the optimal path and potentially end prematurely, in which case an indicator will appear on the score report.
REASONING SCENARIO PERFORMANCE SCORES
Strong Exhibits optimal reasoning that results in positive outcomes in the care of clients and resolution of problems. Satisfactory Exhibits reasoning that results in mildly helpful or neutral outcomes in the care of clients and resolution of problems. Needs Improvement
Exhibits reasoning that results in harmful or detrimental outcomes in the care of clients and resolution of problems.
REASONING SCENARIO PERFORMANCE RELATED TO NURSING COMPETENCY OUTCOMES
A performance indicator is provided for each outcome listed within the nursing competency outcome categories. Percentages are based on the number of questions answered correctly out of the total number of questions that were assigned to the given outcome. Outcomes have varying numbers of questions assigned to them. Also, due to divergent paths within the branching simulation, the outcomes encountered and the number of questions for each outcome can vary. The above factors cause limitations related to comparing scores across students or groups of students.
NCLEX® CLIENT NEED CATEGORIES
Management of Care Providing integrated, cost-effective care to clients by coordinating, supervising, and/or collaborating with members of the multi-disciplinary health care team. Safety and Infection Control
Incorporating preventative safety measures in the provision of client care that provides for the health and well-being of clients, significant others, and members of the health care team. Health Promotion and Maintenance
Providing and directing nursing care that encourages prevention and early detection of illness, as well as the promotion of health.
Psychosocial Integrity
Promoting mental, emotional, and social well-being of clients and significant others through the provision of nursing care.
Basic Care and Comfort
Promoting comfort while helping clients perform activities of daily living.
Pharmacological and Parenteral Therapies
Providing and directing administration of medication, including parenteral therapy.
Reduction of Risk Potential
Providing nursing care that decreases the risk of clients developing health-related complications.
Physiological Adaptation
Providing and directing nursing care for clients experiencing physical illness.
Score Explanation and Interpretation
Individual Performance Profile
atitesting © Assessment Technologies Institute®, Inc.
EX_RealLife_Ind
QUALITY AND SAFETY EDUCATION FOR NURSES (QSEN)
Safety The minimization of risk factors that could cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others.
Patient-Centered Care
The provision of caring and compassionate, culturally sensitive care that is based on a client’s physiological, psychological, sociological, spiritual, and cultural needs, preferences, and values. Evidence Based Practice
The use of current knowledge from research and other credible sources, upon which clinical judgment and client care are based.
Informatics The use of information technology as a communication and information gathering tool that supports clinical decision making and scientifically based nursing practice.
Quality Improvement Care related and organizational processes that involve the development and implementation of a plan to improve health care services and better meet the needs of clients. Teamwork and Collaboration
The delivery of client care in partnership with multidisciplinary members of the health care team, to achieve continuity of care and positive client outcomes.
BODY FUNCTION
Cardiac Output and Tissue Perfusion
The anatomical structures (heart, blood vessels, and blood) and body functions that support adequate cardiac output and perfusion of body tissues.
Cognition and Sensation
The anatomical structures (brain, central and peripheral nervous systems, eyes and ears) and body functions that support perception, interpretation, and response to internal and external stimuli. Excretion The anatomical structures (kidney, ureters, and bladder) and body functions that support filtration and excretion of liquid wastes, regulate fluid and electrolyte and acid-base balance. Immunity The anatomic structures (spleen, thymus, bone marrow, and lymphatic system) and body functions related to inflammation, immunity, and cell growth.
Ingestion, Digestion, Absorption, and Elimination
The anatomical structures (mouth, esophagus, stomach, gall bladder, liver, small and large bowel, and rectum) and body functions that support ingestion, digestion, and absorption of food and elimination of solid wastes from the body.
Integument The anatomical structures (skin, hair, and nails) and body functions related to protecting the inner organs from the external environment and injury.
Mobility The anatomical structures (bones, joints, and muscles) and body functions that support the body and provide its movement.
Oxygenation The anatomical structures (nose, pharynx, larynx, trachea, and lungs) and body functions that support adequate oxygenation of tissues and removal of carbon dioxide.
Regulation and Metabolism
The anatomical structures (pituitary, thyroid, parathyroid, pancreas, and adrenal glands) and body functions that regulate the body’s internal environment.
Reproduction The anatomical structures (breasts, ovaries, fallopian tubes, uterus, vagina, vulva, testicles, prostate, scrotum, and penis) and body functions that support reproductive functions.
DECISION LOG
Information related to each question answered in a scenario attempt is listed in the report. A brief description of the scenario, question, selected option and rationale for that option are provided for each question answered. The words “Optimal Decision” appear next to the question when the most optimal option was selected.
The rationale for each selected option may be used to guide remediation. A variety of learning resources may be used in the review process, including related ATI Review Modules.
If a detrimental decision that could result in grave harm to the client is made during a Real Life scenario, the scenario ends immediately and an indicator that a detrimental decision has been made appears in the score report. A detrimental decision indicates the need to remediate the related topic area to prevent detrimental outcomes in the future.
Score Explanation and Interpretation
Individual Performance Profile
Report (15)
Course: Physical assessment (NURS 190)
University: West Coast University
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