Question

Case Study #2

Angela, a 40 y/o female client, was admitted to the hospital for significant weakness which has

gotten worse over the last year. She attributed the symptoms to working long hours required as

part of her job as a chief executive officer (CEO) of a large corporation. When the symptoms

first started they would resolve with rest so she thought they were due to fatigue. Recently

Angela has had vision changes and difficulty urinating. The nurse has performed an assessment

and obtained the following data: weakness that had been getting worse, tremors, fatigue, slowed

speech, unsteady gait, blurred vision, and numbness.

7. The nurse would develop a plan of care for which priority nursing diagnosis? Write a

diagnosis with at least one AEB and explain rationale.

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NR304 Neurological Case Study

8. What nursing interventions will the nurse have to implement for Angela? List and explain

at least three.

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9. In addition to the neurological assessment, what other assessments should the nurse

complete?

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10. What information should the nurse document as

subjective

? Write it as you would write

in a patient’s chart when documenting the health history.

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Answer 1

7. Priority nursing diagnosis:

Impaired physical mobility related to weakness of muscle.

Rational:

Patient is having muscle weakness, tremer, unsteady gait these problem may contribute into impaired physical mobility.

AEB:

1. Muscle power assessment: muscle weakness.

2. Physical examination : tremer.

3. Subjective data also supportive.

8. Nursing intervention:

1. Encourage and passive ROM exercise.

2. Positiin turning 2 hourly.

3. Prophylaxis measure for deep vein thrombosis.

9. Other assessment:

1. Respiratory assessment.

2. Nutrition assessment for need.

10. Documentation as subjective data:

1. Weakness

2. Fatigue

3. Dysuria

4. Visual disturbance.

5. numbness.