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Fundamentals of Nursing

Competency-Based Assessments

Fundamentals of NursingCompetency-Based Assessments

Competency-Based Assessments

1 .
Outline the key components of nursing interventions for unconscious states.
2 .
Determine and interpret the GCS score for the following scenarios:
  1. Scenario 1: Joel, a 45-year-old construction worker, was brought into the emergency department after falling from a height at a construction site. On arrival, Joel is unconscious and unresponsive. He has a laceration on his forehead and is bleeding profusely.
  2. Scenario 2: Maggie, a 20-year-old college student, was involved in a motor vehicle accident. Emergency medical services bring her to the hospital with complaints of severe headache and confusion. On examination, Maggie is conscious but disoriented. Her eyes open spontaneously, and she obeys commands. She is unable to provide coherent answers to questions about the accident and appears drowsy.
Scenario: Shanda, a 25-year-old patient with a history of ADHD, is admitted to the inpatient unit following a severe asthma exacerbation. She is receiving IV steroid therapy and supplemental oxygen due to respiratory distress. Despite her exhaustion from a sleepless night and the discomfort of her asthma symptoms, Shanda finds it challenging to rest in her hospital room. She is restless, tossing and turning in her bed, unable to find a comfortable position. Shanda becomes increasingly irritable, snapping at nurses and expressing frustration with the constant beeping of IV pumps and monitors. Her attention is easily distracted, and she struggles to focus on conversations or instructions from healthcare providers.
3 .
Is Shanda experiencing sensory overload, sensory deprivation, sensory deficit, or SPD? Please explain your rationale.
4 .
Define the impaired sensory functioning identified in Question 1.
5 .
Identify at least three symptoms associated with the impaired sensory functioning identified in Question 1.
6 .
Identify critical nursing assessments the nurse should perform.
7 .
Identify possible nursing interventions the nurse could implement.
8 .
Outline the potential consequences of prolonged sensory deprivation on patient outcomes.
9 .

Complete the table, identifying the primary characteristics and manifestations of the disorders affecting sensory perception.

Disorder Primary Characteristics Manifestations
Sensory-based motor disorder (SBMD)    
Sensory discrimination disorder (SDD)    
Sensory modulation disorder (SMD)    
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