Nursing Question

Case 3

Case 3
Subjective Data
Chief Complaint
“Annual physical exam”
History of Present Illness (HPI)23-year-old Native American male comes in to see you because he has been having anxiety and wants something to help him. He has been smoking “pot” and says he drinks to help him too. He tells you he is afraid that he will not get into Heaven if he continues in this lifestyle.
Drug HxCurrent Meds: denied
AllergiesNo allergies to food or medications.
Family HxHe has a family history of diabetes, hypertension, and alcoholism.
Review of Systems (ROS)
GeneralNo recent weight gains of losses, fatigue, fever, or chills
CVno chest discomfort or palpitations
Integumenthistory of eczema – not active
MS/Neurono syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements

Objective Data
PEB/P 158/90; Pulse 88; RR 18; Temp 99.2; Ht 5,7; wt 208; BMI 32.6
General23-year-old male appears well developed and well-nourished. He is anxious – pacing in the room and fidgeting, but in no acute distress.
HEENTAtraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries.
CardS1S2, +II/VI holosystolic murmur; without rub or gallop
Abdbenign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.
Extno cyanosis, clubbing or edema
Integumentintact without lesions masses or rashes.
NeuroNo obvious deficits and CN grossly intact II-XII

Once you received your case number, answer the following questions:

  1. Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
  2. Utilizing the five assessment domains, which ones would you utilize on your patients in conducting a comprehensive nutritional assessment.
  3. Discuss the functional anatomy and physiology of a psychiatric mental health patient. Which key concepts must a nurse know in order to assess specific functions?
  4. Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

Please don’t copy, my school uses Turn It In.

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