[Solved] NR 325 CJE

Assignment Prompt & Instructions

– ## Note.docx

– Relearning_Clinical_Judgment_Plan_of_Care_Template_July243.docx

**## Note.docx**

Name: Martha Tass

Age: 88 years

Provider: H. Severs MD

Allergies: sulfonamides

Code Status: DNR

Admit Wt: 118 lbs (53.5 kg)

BMI: 19.6

·
[**Nursing**](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·

·

·

·

·

·
[Other](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

| | |
| — | — |
| **NURSING ASSESSMENT & NOTES** |
| 3/5 1500 | **N>ursing Note:** Report received from J. Young, RN. Client on commode visibly straining and grimacing. Client states, “I just need to sit here a little while.” Reporting small amounts of diarrhea stools leaking from rectum. Call bell given. |
| 3/5 1515 | **Nursing Note:** Client ambulates with a steady gait back to bed. States, “I couldn’t go.” Reports decreased appetite and drink approx. 120 mL of fluid today. “It hurts so much I don’t want anything.” |
| 3/5 1525 | **Nursing Note:** Dr. Severs made aware of client constipation. Verbal orders with readback for verification completed. |
| 3/5 1600 | **Nursing Note:** Medications administered per MAR. Client agreeable to enema. |

Before answering this question, review the client’s health information in the EHR. Identify the data that could contribute or does not contribute to the client’s problem.
**Select one option in each row.**

| | | |
| — | — | — |
| | **Contributing** | **Not Contributing** |
| Surgical History | | |
| Hemorrhoids | | |
| Depression | | |
| Docusate sodium | | |
| Rheumatoid arthritis | | |
| Oxycodone IR | | |

**Feedback**

**Consider:**

1. What are other factors that can contribute to constipation?

2. What medications listed in the client’s EHR impact bowel function?

3. What social factors can impact bowel habits?

**Question 2**

Complete

Mark 0.00 out of 33.34

**Question text**

Name: Martha Tass

Age: 88 years

Provider: H. Severs MD

Allergies: sulfonamides

Code Status: DNR

Admit Wt: 118 lbs (53.5 kg)

BMI: 19.6

·
[Nursing](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·

·
[Provider](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·

·

·

·
[**Other**](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

| | |
| — | — |
| 3/5 1500 | **Medical History:**<br>· Rheumatoid arthritis<br>· Hypertension<br>· Peripheral vascular disease<br>· Depression<br>· Irritable bowel syndrome<br>· Breast cancer<br>· External hemorrhoids<br>· Chronic back pain<br>**Surgical History:**<br>· Hysterectomy<br>· Bilateral radical mastectomy |
| 3/5 1500 | **Home Medications:**<br>· Lisinopril 20 mg by mouth once daily<br>· Escitalopram 20 mg by mouth once daily<br>· Methotrexate 7.5 mg by mouth twice weekly<br>· Oxycodone IR 5 mg by mouth q6h PRN<br>· Acetaminophen 650 mg by mouth q6h PRN<br>· Polyethylene glycol 17 g by mouth daily PRN<br>· Docusate sodium 100 mg by mouth three times daily PRN |

Before answering this question, review the client’s health information in the EHR.
**Complete the sentence using the drop-down choices.**

The nurse recognizes that the priority action is to Blank 1 Question 2 encouraging oral fluidsadminister enemaadministering a stool softenerambulating the client . The nurse will need to Blank 2 Question 2 assess bowel soundsmonitor intakemonitor for dizzinessobtain an abdominal x-ray .

**Feedback**

**Consider:**

1. What education should the nurse provide to the client before the enema?

2. What equipment should the nurse gather?

3. Are there any contraindications to completing an enema?

**Question 3**

Complete

Mark 0.00 out of 33.33

**Question text**

Name: Martha Tass

Age: 88 years

Provider: H. Severs MD

Allergies: sulfonamides

Code Status: DNR

Admit Wt: 118 lbs (53.5 kg)

BMI: 19.6

·
[Nursing](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·
[Flowsheets](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·
[Provider](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·

·

·

·
[**Other**](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

| | |
| — | — |
| 3/5 1500 | **Medical History:**<br>· Rheumatoid arthritis<br>· Hypertension<br>· Peripheral vascular disease<br>· Depression<br>· Irritable bowel syndrome<br>· Breast cancer<br>· External hemorrhoids<br>· Chronic back pain<br>**Surgical History:**<br>· Hysterectomy<br>· Bilateral radical mastectomy |
| 3/5 1500 | **Home Medications:**<br>· Lisinopril 20 mg by mouth once daily<br>· Escitalopram 20 mg by mouth once daily<br>· Methotrexate 7.5 mg by mouth twice weekly<br>· Oxycodone IR 5 mg by mouth q6h PRN<br>· Acetaminophen 650 mg by mouth q6h PRN<br>· Docusate sodium 100 mg by mouth three times daily PRN |
| 3/5 1650 | **Client & Family Education:**<br>**What:** Bowel Training<br>**Goals:** Client will verbalize methods of promoting improved gastric emptying.<br>**Interventions:**<br>· Toilet approximately one hour after meals<br>· Toilet at the same time every day<br>· Drink warmed fluids with meals<br>· Support legs during toileting<br>· Unhurried, private environment<br>· Position client to lean forward, press hand gently on abdomen<br>· Discourage straining<br>· Pelvic floor muscle strengthening |

Before answering this question, review the client’s health information in the EHR. Identify statements from the client that require additional teaching from the nurse.
**Select the correct answer using the drop-down choices in each group.**

**Nutrition:** Blank 1 Question 3 "I need at least 30 grams of fiber.""I drink warmed fluids at each meal, so I don’t need to drink much.""I like drinking warmed cider or coffee at each meal."

**Constipation Pathophysiology:** Blank 2 Question 3 "My other medical problems can make constipation worse.""I need to keep using the bowel stimulants every day.""Chewing my food well can help reduce constipation"

**Bowel Training:** Blank 3 Question 3 "I can set my legs on a stool to create a better position.""I can use Kegel exercises to help strengthen those muscles.""If I don’t feel any urge, I should wait to go to the bathroom."

**Feedback**

**Consider:**

1. What additional teachings should the nurse provide the client?

2. How should the nurse respond to a client becoming frustrated with lack of results during bowel training?

3. Review with a classmate how you would educate a client on Kegel exe

**Relearning_Clinical_Judgment_Plan_of_Care_Template_July243.docx**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/relearning-clinical-judgment-plan-of-care-template-july243-docx)

**Relearning_Clinical_Judgment_Plan_of_Care_Template_July243.docx**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/relearning-clinical-judgment-plan-of-care-template-july243-docx)

**## Note.docx**

Name: Martha Tass

Age: 88 years

Provider: H. Severs MD

Allergies: sulfonamides

Code Status: DNR

Admit Wt: 118 lbs (53.5 kg)

BMI: 19.6

·
[**Nursing**](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·

·

·

·

·

·
[Other](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

| | |
| — | — |
| **NURSING ASSESSMENT & NOTES** |
| 3/5 1500 | **N>ursing Note:** Report received from J. Young, RN. Client on commode visibly straining and grimacing. Client states, “I just need to sit here a little while.” Reporting small amounts of diarrhea stools leaking from rectum. Call bell given. |
| 3/5 1515 | **Nursing Note:** Client ambulates with a steady gait back to bed. States, “I couldn’t go.” Reports decreased appetite and drink approx. 120 mL of fluid today. “It hurts so much I don’t want anything.” |
| 3/5 1525 | **Nursing Note:** Dr. Severs made aware of client constipation. Verbal orders with readback for verification completed. |
| 3/5 1600 | **Nursing Note:** Medications administered per MAR. Client agreeable to enema. |

Before answering this question, review the client’s health information in the EHR. Identify the data that could contribute or does not contribute to the client’s problem.
**Select one option in each row.**

| | | |
| — | — | — |
| | **Contributing** | **Not Contributing** |
| Surgical History | | |
| Hemorrhoids | | |
| Depression | | |
| Docusate sodium | | |
| Rheumatoid arthritis | | |
| Oxycodone IR | | |

**Feedback**

**Consider:**

1. What are other factors that can contribute to constipation?

2. What medications listed in the client’s EHR impact bowel function?

3. What social factors can impact bowel habits?

**Question 2**

Complete

Mark 0.00 out of 33.34

**Question text**

Name: Martha Tass

Age: 88 years

Provider: H. Severs MD

Allergies: sulfonamides

Code Status: DNR

Admit Wt: 118 lbs (53.5 kg)

BMI: 19.6

·
[Nursing](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·

·
[Provider](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·

·

·

·
[**Other**](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

| | |
| — | — |
| 3/5 1500 | **Medical History:**<br>· Rheumatoid arthritis<br>· Hypertension<br>· Peripheral vascular disease<br>· Depression<br>· Irritable bowel syndrome<br>· Breast cancer<br>· External hemorrhoids<br>· Chronic back pain<br>**Surgical History:**<br>· Hysterectomy<br>· Bilateral radical mastectomy |
| 3/5 1500 | **Home Medications:**<br>· Lisinopril 20 mg by mouth once daily<br>· Escitalopram 20 mg by mouth once daily<br>· Methotrexate 7.5 mg by mouth twice weekly<br>· Oxycodone IR 5 mg by mouth q6h PRN<br>· Acetaminophen 650 mg by mouth q6h PRN<br>· Polyethylene glycol 17 g by mouth daily PRN<br>· Docusate sodium 100 mg by mouth three times daily PRN |

Before answering this question, review the client’s health information in the EHR.
**Complete the sentence using the drop-down choices.**

The nurse recognizes that the priority action is to Blank 1 Question 2 encouraging oral fluidsadminister enemaadministering a stool softenerambulating the client . The nurse will need to Blank 2 Question 2 assess bowel soundsmonitor intakemonitor for dizzinessobtain an abdominal x-ray .

**Feedback**

**Consider:**

1. What education should the nurse provide to the client before the enema?

2. What equipment should the nurse gather?

3. Are there any contraindications to completing an enema?

**Question 3**

Complete

Mark 0.00 out of 33.33

**Question text**

Name: Martha Tass

Age: 88 years

Provider: H. Severs MD

Allergies: sulfonamides

Code Status: DNR

Admit Wt: 118 lbs (53.5 kg)

BMI: 19.6

·
[Nursing](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·
[Flowsheets](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·
[Provider](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·

·

·

·
[**Other**](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

| | |
| — | — |
| 3/5 1500 | **Medical History:**<br>· Rheumatoid arthritis<br>· Hypertension<br>· Peripheral vascular disease<br>· Depression<br>· Irritable bowel syndrome<br>· Breast cancer<br>· External hemorrhoids<br>· Chronic back pain<br>**Surgical History:**<br>· Hysterectomy<br>· Bilateral radical mastectomy |
| 3/5 1500 | **Home Medications:**<br>· Lisinopril 20 mg by mouth once daily<br>· Escitalopram 20 mg by mouth once daily<br>· Methotrexate 7.5 mg by mouth twice weekly<br>· Oxycodone IR 5 mg by mouth q6h PRN<br>· Acetaminophen 650 mg by mouth q6h PRN<br>· Docusate sodium 100 mg by mouth three times daily PRN |
| 3/5 1650 | **Client & Family Education:**<br>**What:** Bowel Training<br>**Goals:** Client will verbalize methods of promoting improved gastric emptying.<br>**Interventions:**<br>· Toilet approximately one hour after meals<br>· Toilet at the same time every day<br>· Drink warmed fluids with meals<br>· Support legs during toileting<br>· Unhurried, private environment<br>· Position client to lean forward, press hand gently on abdomen<br>· Discourage straining<br>· Pelvic floor muscle strengthening |

Before answering this question, review the client’s health information in the EHR. Identify statements from the client that require additional teaching from the nurse.
**Select the correct answer using the drop-down choices in each group.**

**Nutrition:** Blank 1 Question 3 "I need at least 30 grams of fiber.""I drink warmed fluids at each meal, so I don’t need to drink much.""I like drinking warmed cider or coffee at each meal."

**Constipation Pathophysiology:** Blank 2 Question 3 "My other medical problems can make constipation worse.""I need to keep using the bowel stimulants every day.""Chewing my food well can help reduce constipation"

**Bowel Training:** Blank 3 Question 3 "I can set my legs on a stool to create a better position.""I can use Kegel exercises to help strengthen those muscles.""If I don’t feel any urge, I should wait to go to the bathroom."

**Feedback**

**Consider:**

1. What additional teachings should the nurse provide the client?

2. How should the nurse respond to a client becoming frustrated with lack of results during bowel training?

3. Review with a classmate how you would educate a client on Kegel exe

**Relearning_Clinical_Judgment_Plan_of_Care_Template_July243.docx**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/relearning-clinical-judgment-plan-of-care-template-july243-docx)

**## Note.docx**

Name: Martha Tass

Age: 88 years

Provider: H. Severs MD

Allergies: sulfonamides

Code Status: DNR

Admit Wt: 118 lbs (53.5 kg)

BMI: 19.6

·
[**Nursing**](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·

·

·

·

·

·
[Other](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

| | |
| — | — |
| **NURSING ASSESSMENT & NOTES** |
| 3/5 1500 | **N>ursing Note:** Report received from J. Young, RN. Client on commode visibly straining and grimacing. Client states, “I just need to sit here a little while.” Reporting small amounts of diarrhea stools leaking from rectum. Call bell given. |
| 3/5 1515 | **Nursing Note:** Client ambulates with a steady gait back to bed. States, “I couldn’t go.” Reports decreased appetite and drink approx. 120 mL of fluid today. “It hurts so much I don’t want anything.” |
| 3/5 1525 | **Nursing Note:** Dr. Severs made aware of client constipation. Verbal orders with readback for verification completed. |
| 3/5 1600 | **Nursing Note:** Medications administered per MAR. Client agreeable to enema. |

Before answering this question, review the client’s health information in the EHR. Identify the data that could contribute or does not contribute to the client’s problem.
**Select one option in each row.**

| | | |
| — | — | — |
| | **Contributing** | **Not Contributing** |
| Surgical History | | |
| Hemorrhoids | | |
| Depression | | |
| Docusate sodium | | |
| Rheumatoid arthritis | | |
| Oxycodone IR | | |

**Feedback**

**Consider:**

1. What are other factors that can contribute to constipation?

2. What medications listed in the client’s EHR impact bowel function?

3. What social factors can impact bowel habits?

**Question 2**

Complete

Mark 0.00 out of 33.34

**Question text**

Name: Martha Tass

Age: 88 years

Provider: H. Severs MD

Allergies: sulfonamides

Code Status: DNR

Admit Wt: 118 lbs (53.5 kg)

BMI: 19.6

·
[Nursing](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·

·
[Provider](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·

·

·

·
[**Other**](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

| | |
| — | — |
| 3/5 1500 | **Medical History:**<br>· Rheumatoid arthritis<br>· Hypertension<br>· Peripheral vascular disease<br>· Depression<br>· Irritable bowel syndrome<br>· Breast cancer<br>· External hemorrhoids<br>· Chronic back pain<br>**Surgical History:**<br>· Hysterectomy<br>· Bilateral radical mastectomy |
| 3/5 1500 | **Home Medications:**<br>· Lisinopril 20 mg by mouth once daily<br>· Escitalopram 20 mg by mouth once daily<br>· Methotrexate 7.5 mg by mouth twice weekly<br>· Oxycodone IR 5 mg by mouth q6h PRN<br>· Acetaminophen 650 mg by mouth q6h PRN<br>· Polyethylene glycol 17 g by mouth daily PRN<br>· Docusate sodium 100 mg by mouth three times daily PRN |

Before answering this question, review the client’s health information in the EHR.
**Complete the sentence using the drop-down choices.**

The nurse recognizes that the priority action is to Blank 1 Question 2 encouraging oral fluidsadminister enemaadministering a stool softenerambulating the client . The nurse will need to Blank 2 Question 2 assess bowel soundsmonitor intakemonitor for dizzinessobtain an abdominal x-ray .

**Feedback**

**Consider:**

1. What education should the nurse provide to the client before the enema?

2. What equipment should the nurse gather?

3. Are there any contraindications to completing an enema?

**Question 3**

Complete

Mark 0.00 out of 33.33

**Question text**

Name: Martha Tass

Age: 88 years

Provider: H. Severs MD

Allergies: sulfonamides

Code Status: DNR

Admit Wt: 118 lbs (53.5 kg)

BMI: 19.6

·
[Nursing](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·
[Flowsheets](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·
[Provider](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

·

·

·

·
[**Other**](https://learning.nursethink.com/mod/quiz/review.php?attempt=5399403&cmid=926)

| | |
| — | — |
| 3/5 1500 | **Medical History:**<br>· Rheumatoid arthritis<br>· Hypertension<br>· Peripheral vascular disease<br>· Depression<br>· Irritable bowel syndrome<br>· Breast cancer<br>· External hemorrhoids<br>· Chronic back pain<br>**Surgical History:**<br>· Hysterectomy<br>· Bilateral radical mastectomy |
| 3/5 1500 | **Home Medications:**<br>· Lisinopril 20 mg by mouth once daily<br>· Escitalopram 20 mg by mouth once daily<br>· Methotrexate 7.5 mg by mouth twice weekly<br>· Oxycodone IR 5 mg by mouth q6h PRN<br>· Acetaminophen 650 mg by mouth q6h PRN<br>· Docusate sodium 100 mg by mouth three times daily PRN |
| 3/5 1650 | **Client & Family Education:**<br>**What:** Bowel Training<br>**Goals:** Client will verbalize methods of promoting improved gastric emptying.<br>**Interventions:**<br>· Toilet approximately one hour after meals<br>· Toilet at the same time every day<br>· Drink warmed fluids with meals<br>· Support legs during toileting<br>· Unhurried, private environment<br>· Position client to lean forward, press hand gently on abdomen<br>· Discourage straining<br>· Pelvic floor muscle strengthening |

Before answering this question, review the client’s health information in the EHR. Identify statements from the client that require additional teaching from the nurse.
**Select the correct answer using the drop-down choices in each group.**

**Nutrition:** Blank 1 Question 3 "I need at least 30 grams of fiber.""I drink warmed fluids at each meal, so I don’t need to drink much.""I like drinking warmed cider or coffee at each meal."

**Constipation Pathophysiology:** Blank 2 Question 3 "My other medical problems can make constipation worse.""I need to keep using the bowel stimulants every day.""Chewing my food well can help reduce constipation"

**Bowel Training:** Blank 3 Question 3 "I can set my legs on a stool to create a better position.""I can use Kegel exercises to help strengthen those muscles.""If I don’t feel any urge, I should wait to go to the bathroom."

**Feedback**

**Consider:**

1. What additional teachings should the nurse provide the client?

2. How should the nurse respond to a client becoming frustrated with lack of results during bowel training?

3. Review with a classmate how you would educate a client on Kegel exe

**Relearning_Clinical_Judgment_Plan_of_Care_Template_July243.docx**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/relearning-clinical-judgment-plan-of-care-template-july243-docx)

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