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Rosa Jimenez is a 28-year-old female who was admitted to the emergency department to rule out injury
related to a fall while bicycling. She was not wearing a helmet. She has no significant medical history and no allergies.
Examination data: Alert and slightly anxious female in pain and guarding the right side of her mouth and face. Her vital
signs are: heart rate of 110 beats/min, respirations of 24 breaths/min, blood pressure 134/86 mmHg, temperature of 99.0
degrees Fahrenheit, oxygen saturation of 93% on room air, and pain 7/10 (0-10 scale) in the right side of her mouth and
face. Upon external examination; she has edema, tenderness, and ecchymoses on the right jaw and face. Blood and drool
are emptying mostly out of the right side of the mouth. The right mandible is tender with crepitus, and is independently
mobile to manual manipulation by the examiner. The patient has difficulty swallowing and talking. She is unable to open
her mouth fully and opening/closing of the mouth increases the pain. Her lower lip is numb and she reports the lower
right teeth are out of alignment with the upper right teeth. Upon internal examination, she has an intraoral laceration with
bleeding, several loose teeth, edema, a sublingual hematoma and the right lower teeth are out of alignment with the rest
of the lower teeth. For Ms. Jimenez,
3. Identify potential medical diagnosis(es) related to abnormalities in the oropharynx. Explain abnormal
findings that support diagnosis. (20 points)
4. Identify all NANDA nursing diagnoses labels (just the label!) that apply to this patient (e.g., impaired
swallowing). Identify the priority (#1) nursing diagnosis label; and for the (#1) nursing diagnosis label,
explain the nursing interventions to address the identified problem. Provide evidence-based rationale to
explain the need and/or benefit of each intervention. For interventions, include what the nurse should
“monitor/assess”, “do”, and “teach” to the client. (20 points)
5. Discuss one potential healthcare referral need for the client and explain the need and/or benefit. (10
points
SCIENCE
HEALTH SCIENCE
NURSING
