Amanda Blaire Room 301: You Responded Correctly To 4 Out of 6 Evaluations

Amanda Blaire Room 301
Amanda Blaire, 14-year-old female, who was in an ATV accident and now has a fractured tibia and fibula.
Her vital signs are Temperature 98.6, HR 87, BP 111/72, RR 18, PaO2 97%. She is post-op day 1 with
continuous traction and skeletal pins to immobilize leg.
You responded correctly to 4 out of 6 evaluations:
Category Your response Explanation

Educational Needs Normal acuity Status Assessment reports fracture and surgery and rehabilitation needs.
Health Normal acuity Status Assessment reports fractures, major surgery, and rehabilitation needs.
LOC Normal acuity Status assessment reports no indication of increased LOC acuity
Pain Increased acuity Status Assessment reports fractures, major surgery, and rehabilitation needs.
Psych Normal acuity Status assessment reports no indication of increased Psychiatric acuity
Safety Increased acuity Status Assessment reports fractures, major surgery, and rehabilitation needs.
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Amanda Blaire
14-year-old female, who was in an ATV accident and now has a fractured tibia and fibula. Her vital signs
are Temperature 98.6, HR 87, BP 111/72, RR 18, PaO2 97%. She is post-op day 1 with continuous traction
and skeletal pins to immobilize leg.
You correctly diagnosed 8 out of 9 options:
Physiological
Your
Description Response Explanation
Acute pain True Status assessment reports fractured tib/fib and continuous tra
skeletal pins.
Constipation False Patient is at risk for Constipation.
Your
Description Response Explanation
Impaired mobility True Status assessment reports fractured leg and continuous tract
immobilized leg.
Impaired skin integrity True Status assessment reports is post op with skeletal pins.
Nutrition, altered less than body False Status assessment reports no indication of Nutrition, less than
requirements requirements
Risk for infection True Status assessment reports Post op.
Tissue Perfusion, altered False Status assessment reports no indication of Tissue Perfusion, a
Safety
Description Your Response Explanation

Infection True Patient is at risk for Infection
Knowledge deficit True Education will be needed for post op, continuous traction, and skeletal pins.
Amanda Blaire Scenario 1

Amanda is due now for a scheduled 2-hour position change.
You correctly ordered 5 out of 5 actions:
Your Correct
order order Step Explanation
1 1 Assess for pain and administer pain medication if needed Pain can be increased with changing pos
treat pain in a timely manner
2 2 Instruct patient about the position change and what Ensures more cooperation from the patie
position will be achieved
3 3 Have Amanda use grab bar over bed to assist with turning Assists with the change in position
from left side to right side
4 4 Inspect skin for signs of breakdown When a patient is bedbound there is an
of skin breakdown
5 5 Use pillows to position Amanda in proper alignment Ensures comfort and decreased chance
Scenario 2
Amanda is complaining of increased pain in her injured leg.
Your Correct
1 1 Assess toes for pain, pallor, paresthesia, paralysis, and Ensure cast is not too tight
pulse
2 2 Assess traction setting to ensure proper alignment Misalignment can increase pain
3 3 Reposition Amanda to more comfortable side Non-pharmacologic pain relief measure
4 4 Look up pain medication administration schedule and Ensures pain medication is given at co
administer if can be given dose
5 5 Reassess pain level in 30 minutes and document findings Always reassess after an intervention t
effectiveness of intervention
Scenario 3
Amanda is scheduled for pin care to the affected site. The nurse has read the order and gathered supplies
for the procedure. Amanda has been informed of the procedure.
Your Correct
1 1 Wash hands Proper hand hygiene helps decrease infection
2 2 Don clean gloves and remove old dressing, Clean gloves are needed to remove old dressing, dressing
dispose of dressing in red bag so needs to go in red bag
3 3 Wash hands, put on sterile gloves Proper hand hygiene for sterile procedure
4 4 Apply prescribed medication around pin This is proper procedure to ensure reduction of infection
site in a circular motion from inside out
5 5 Redress pin site, wash hands Must be kept clean and covered to prevent infection, alw
after procedure to decrease risk of infection or cross cont
Scenario 4
Amanda is learning to walk with crutches. She is concerned because she has never used crutches before.
Your Correct
1 1 Explain crutch walking to Amanda Need to explain the procedure to increase knowled
2 2 Measure and adjust crutches to Amanda’s Ensures proper fit of crutches
height
3 3 Have Amanda balance on the crutches first Ensure that she can balance before trying to walk
4 4 Help Amanda crutch walk in the room Want to try crutches in a safe environment and ad
needed
5 5 Document teaching and demonstration Part of the medical record – demonstrates activity
Scenario 5
Amanda is now ready for discharge.
Your Correct
1 1 Observe Amanda walking with crutches ensures understanding of teaching crutch walking an
appropriately
2 2 Provide prescriptions for antibiotics and pain given just prior to discharge to promote healing
medications
3 3 Provide written and oral discharge ensure patient understands instructions and has cop
instructions to refer to when home
4 4 Ask Amanda and parents if they have any need to ensure all questions answered prior to disch
further questions
5 5 Discharge Amanda to home in a wheelchair safety of patient in discharging to home
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Amanda Blaire Room 301

You responded correctly to 4 out of 6 evaluations:

Category Your response Explanation

You correctly diagnosed 8 out of 9 options:

Description Your Response Explanation

Amanda Blaire Scenario 1

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