______________&&&7. CASE 3: A 15-year-old girl who is a victim of physical and sexual abuse is brought to the health care facility by her mother for a physical examination. She appears scared, tense, and nervous. She requests that the nurse not examine certain parts of her body and asks whether her mother could be present during the examination a. Describe actions the nurse should take during the physical examination to make the client more comfortable while collecting the required assessment data b. What

______________&&&7. CASE 3: A 15-year-old girl who is a victim of physical and sexual abuse is brought to the health care facility by her mother for a physical examination. She appears scared, tense, and nervous. She requests that the nurse not examine certain parts of her body and asks whether her mother could be present during the examination a. Describe actions the nurse should take during the physical examination to make the client more comfortable while collecting the required assessment data b. What

Essentials Health Info Management Principles/Practices

4th Edition

ISBN:9780357191651

Author:Bowie

Publisher:Bowie

Chapter6: Patient Record Documentation Guidelines: Inpatient, Outpatient, And Physician Office

Section6.3: Hospital Inpatient Record— Clinical Data

Problem 9E

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case study: SITUATION: Miss Hermione Granger, a 5-year-old girl, was brought in by ambulance accompanied by her mother following a collision with a car whilst riding her bicycle. The collision was at low speed. The injuries she sustained include a suspected fracture of her left tibia and fibula, multiple grazes across her legs and feet, left hip, and shoulder. She has a 5cm laceration on her left elbow. Hermione was wearing her helmet but sustained a small graze above her left eyebrow. BACKGROUND Miss Hermione Granger has no past medical and surgical histories. She lives at home with her parents and a younger brother. Miss Hermione Granger was born at 38 weeks' gestation with no neonatal complications. Her immunization is up to date. ASSESSMENT Her Glasgow Coma Scale (GCS) is 15, moving right upper and lower limbs with mild weakness, mild weakness in left upper limb and severe weakness in left lower limb. Both her pupils are equal and reactive to light. Her vital signs are as…
case study: SITUATION: Miss Hermione Granger, a 5-year-old girl, was brought in by ambulance accompanied by her mother following a collision with a car whilst riding her bicycle. The collision was at low speed. The injuries she sustained include a suspected fracture of her left tibia and fibula, multiple grazes across her legs and feet, left hip, and shoulder. She has a 5cm laceration on her left elbow. Hermione was wearing her helmet but sustained a small graze above her left eyebrow. BACKGROUND Miss Hermione Granger has no past medical and surgical histories. She lives at home with her parents and a younger brother. Miss Hermione Granger was born at 38 weeks' gestation with no neonatal complications. Her immunization is up to date. ASSESSMENT Her Glasgow Coma Scale (GCS) is 15, moving right upper and lower limbs with mild weakness, mild weakness in left upper limb and severe weakness in left lower limb. Both her pupils are equal and reactive to light. Her vital signs are as…
Mary Brown [MB] is a healthy 36-year-old woman with complaints of persistent generalized fatigue. At her annual checkup, her vital signs: heart rate (HR), 118 beats/min; blood pressure (BP), 110/60 mm Hg; oral temperature, 37°C; and respiratory rate (RR), 26 breaths/min. Her skin, conjunctiva and nail beds are pale. Laboratory results: hematocrit (Hct), 27%; hemoglobin (Hb), 9 g/dL and hypochromatic red blood cells (RBCs) are present. Which of MB’s clinical signs are reflective of the body’s effort to compensate for the decreased oxygen carrying capacity seen with this condition?
Mary Brown [MB] is a healthy 36-year-old woman with complaints of persistent generalized fatigue. At her annual checkup, her vital signs: heart rate (HR), 118 beats/min; blood pressure (BP), 110/60 mm Hg; oral temperature, 37°C; and respiratory rate (RR), 26 breaths/min. Her skin, conjunctiva and nail beds are pale. Laboratory results: hematocrit (Hct), 27%; hemoglobin (Hb), 9 g/dL and hypochromatic red blood cells (RBCs) are present. What other history data would be helpful in determining the cause of this disorder?
Mary Brown [MB] is a healthy 36-year-old woman with complaints of persistent generalized fatigue. At her annual checkup, her vital signs: heart rate (HR), 118 beats/min; blood pressure (BP), 110/60 mm Hg; oral temperature, 37°C; and respiratory rate (RR), 26 breaths/min. Her skin, conjunctiva and nail beds are pale. Laboratory results: hematocrit (Hct), 27%; hemoglobin (Hb), 9 g/dL and hypochromatic red blood cells (RBCs) are present. What type of hematologic disorder would you suspect based on MB’s laboratory values? Why?
Mary Brown [MB] is a healthy 36-year-old woman with complaints of persistent generalized fatigue. At her annual checkup, her vital signs: heart rate (HR), 118 beats/min; blood pressure (BP), 110/60 mm Hg; oral temperature, 37°C; and respiratory rate (RR), 26 breaths/min. Her skin, conjunctiva and nail beds are pale. Laboratory results: hematocrit (Hct), 27%; hemoglobin (Hb), 9 g/dL and hypochromatic red blood cells (RBCs) are present. MB is counseled to increase her dietary intake of iron-containing foods. What kinds of food would be recommended?
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Mrs. Reyes, 71 yearsold, while doing household chores has fallen her front steps. She had a large bruise on her right temple and her right face and is brought to the emergency. Upon assessment her vital signs are HR 125; BP 110/76; RR 16; T 37.6C ; pain 4/10 Question: document a brief NEUROLOGIC exam on the patient
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M.H. is an 80-year-old Caucasian female who is married and lives with her spouse. She presents to your office today with her spouse, feeling “coocoo, I just don’t feel right.” Currently she is taking rosuvastatin prescribed by her cardiologist for hyperlipidemia and a daily 325 mg aspirin. She drinks 3–6 hard liquor drinks a day, 3–4 times a week in the evening, and has a 65-year smoking habit, currently smoking two packs per day (ppd). She has no known allergies. Past surgical history includes hysterectomy for a benign fibroid. Family history of breast cancer in three sisters, Type 2 diabetes and CVA in one sister, cancer of unknown origin in one brother. All siblings and parents are deceased. Her husband reports that she is hard of hearing. He feels that it is due to cerumen build-up in her ears. She refuses to have the buildup removed. Her husband is also worried about her memory—states that she “just does not remember things like she used to. She keeps asking me the same questions…
KINDLY PROVIDE 2 SIGNIFICANT DIFFERENCES EACH TERMS