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Clinical Nursing Skills

What Should the Nurse Do?

Clinical Nursing SkillsWhat Should the Nurse Do?

What Should the Nurse Do?

The nurse is caring for a 12-year-old patient who complains of ear pain to the right ear for four days. Pain rated 7/10 on the numerical scale. Temperature is 99.9°F (37.7°C), pulse is 87, blood pressure is 115/64, oxygen saturation is 100 percent on room air.

Scenario update: The external auditory canal is clear and not reddened. The tympanic membrane is bulging and red. The patient reports having had reoccurring ear infections since childhood.

1 .
Which symptoms are concerning (identifying cues)?
2 .
What additional information is needed (analyzing cues)?
3 .
What do you think is going on with the patient (prioritizing hypothesis)?
A patient presents to the doctor complaining of a sore throat for the past three days. Upon physical assessment, the nurse notes the patient’s throat is red, tonsils measure grade 3+, and voice is hoarse. Pertinent past medical history includes strep throat, tonsillectomy, and seasonal allergies.
4 .
What assessment data provide conflicting information?
5 .
What should the nurse do prior to documenting the findings?
6 .
What additional assessment data are needed?

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