kaplan management quiz 2

25 flashcards

The nurse assesses a postoperative patient. Which finding does the nurse document as subjective data? 1. Laboratory test results. 2. Patient’s description of pain. 3. Vital signs. 4. Electrocardiographic waveforms.

Correct answer: 2. Patient’s description of pain. Rationales: 1. These test results are measured the same way for every individual by precision equipment. They are objective data. 2. This data comes directly from the patient and is usually recorded as a direct quotation that reflects the patient’s opinions or feelings about a situation. 3. This data is measured by a standardized process for every individual. 4. This data is obtained through the use of standardized equipment. Think Like a Nurse: When conducting an assessment, you will categorize collected data as being either subjective or objective. Subjective data is information that is reported by someone else. In this scenario, it is the patient who is reporting the data. Anything that a patient says is considered subjective data. Although pain level can be quantified with a pain rating scale, the presence of pain is a subjective experience. On the other hand, objective data is information that can be measured and observed by others. This type of data includes vital sign measurements, laboratory values, and cardiac monitor waveform tracings.

The nurse provides care for a patient under legal guardianship. The health care provider ordered an x-ray of the wrist to rule out a fracture. The patient is alert, but refusing the x-ray. Which action does the nurse take? (Select all that apply.) 1. Phones the legal guardian to discuss the procedure and options. 2. Complies with the patient’s request to refuse the x-ray. 3. Takes the patient to the radiology department immediately. 4. Requests that the health care provider convince the patient to consent to the x-ray. 5. Cancels the x-ray and documents “patient refused” in the medical record.

Correct answer: 1. Phones the legal guardian to discuss the procedure and options. NCLEX Tip: with a "select all that apply" question, only 1 answer may be correct, more than 1 answer may be correct, or all answer options may be correct. 1) CORRECT - Patients under legal guardianship have lost mental competence to make medical decisions for themselves. The patient cannot refuse until the nurse speaks with the legal guardian. 2) INCORRECT - The patient is under legal guardianship, meaning the patient cannot make informed decisions without the surrogate decision-maker being present or consulted. 3) INCORRECT - In this case, the wishes of the guardian should be followed. The nurse must speak with the guardian prior to taking the patient to the radiology department. 4) INCORRECT - The legal guardian must be consulted prior to procedures. 5) INCORRECT - The patient cannot refuse the procedure. Additionally, the health care provider who prescribed the test is responsible for canceling the test.

The nurse cares for a middle-aged adult patient in the emergency department (ED). 1850: Patient presents to the ED with “crushing” chest pain rated 8/10 that radiates down the left shoulder. Pain began 2 hours ago while push-mowing grass. Patient states, “At first I thought I was just having bad heartburn, but it keeps getting worse.” Patient reports shortness of breath with exertion and nausea that began with the pain. History: Hypertension. Smokes 1 pack of cigarettes per day for 30 years. Home medications: None. Denies pharmacological treatment of hypertension. Vital signs: BP 170/92 mmHg, HR 110/min, RR 24/min, SpO2 93% on room air, and oral temperature 98.9°F (37.2°C). Assessment: Integumentary: Cool, pale, diaphoretic. Cardiovascular: Heart rhythm regular. Normal S1 and S2. II/VI holosystolic murmur appreciated at the left sternal border. Pulses 2+ all extremities. Respiratory: Crackles in the bases bilaterally. Gastrointestinal: Abdomen non-tender, non-distended. Neurological: Alert and oriented. Restless. The nurse reviews the admission note and assessment. Identify the findings below that concern the nurse. Select at least one. Integumentary: Cool, pale, diaphoretic. Cardiovascular: Heart rhythm regular. Normal S1 and S2. II/VI holosystolic murmur appreciated at the left sternal border. Respiratory: Crackles in the bases bilaterally. Gastrointestinal: Abdomen non-tender, non-distended. Neurological: Restless.

Correct answer: Cool, pale, diaphoretic; II/VI holosystolic murmur appreciated at the left sternal border; crackles in the bases bilaterally; restless. The nurse is concerned the patient has cool, pale, clammy skin. The II/VI systolic murmur could indicate mitral regurgitation and is not an expected finding. Crackles in the lung bases are concerning for pulmonary edema. The patient's restlessness is a concern and could indicate hypoxia or could be a response to the pain. A regular heart rhythm is a positive finding, as is the S1 and S2 heart sounds. The abdomen being non-tender and non-distended is not a concern.

The nurse cares for a middle-aged adult patient in the emergency department (ED). 1850: Patient presents to the ED with “crushing” chest pain rated 8/10 that radiates down the left shoulder. Pain began 2 hours ago while push-mowing grass. Patient states, “At first I thought I was just having bad heartburn, but it keeps getting worse.” Patient reports shortness of breath with exertion and nausea that began with the pain. History: Hypertension. Smokes 1 pack of cigarettes per day for 30 years. Home medications: None. Denies pharmacological treatment of hypertension. Vital signs: BP 170/92 mmHg, HR 110/min, RR 24/min, SpO2 93% on room air, and oral temperature 98.9°F (37.2°C). Assessment: Integumentary: Cool, pale, diaphoretic. Cardiovascular: Heart rhythm regular. Normal S1 and S2. II/VI holosystolic murmur appreciated at the left sternal border. Pulses 2+ all extremities. Respiratory: Crackles in the bases bilaterally. Gastrointestinal: Abdomen non-tender, non-distended. Neurological: Alert and oriented. Restless. For each assessment finding, specify whether the finding is most consistent with pneumonia, myocardial infarction, or pulmonary embolism. Each finding may support more than one disease process. Each finding must have at least one response. Crushing, radiating chest pain. Dyspnea. Tachycardia. Cool, pale skin.

Correct answer: Crushing, radiating chest pain: Myocardial infarction. Dyspnea: Pneumonia, myocardial infarction, and pulmonary embolism. Tachycardia: Pneumonia, myocardial infarction, and pulmonary embolism. Cool, pale skin: Myocardial infarction and pulmonary embolism. Chest pain is a potential symptom of pneumonia, myocardial infarction, and pulmonary embolism. The crushing and radiating characteristics of the patient's chest pain are most consistent with myocardial infarction. Dyspnea and tachycardia can be expected for a patient experiencing pneumonia, myocardial infarction, and pulmonary embolism. Tachycardia can be expected due to sympathetic nervous system stimulation. The patient's pale, sweaty skin is most likely associated with a myocardial infarction. Skin can be diaphoretic in a patient with a PE as well, but is typically more flushed or cyanotic. A patient with pneumonia is more likely to have hot, flushed skin, and sweating may be due to fever.

The nurse cares for a middle-aged adult patient in the emergency department (ED). 1850: Patient presents to the ED with “crushing” chest pain rated 8/10 that radiates down the left shoulder. Pain began 2 hours ago while push-mowing grass. Patient states, “At first I thought I was just having bad heartburn, but it keeps getting worse.” Patient reports shortness of breath with exertion and nausea that began with the pain. History: Hypertension. Smokes 1 pack of cigarettes per day for 30 years. Home medications: None. Denies pharmacological treatment of hypertension. Vital signs: BP 170/92 mmHg, HR 110/min, RR 24/min, SpO2 93% on room air, and oral temperature 98.9°F (37.2°C). Assessment: Integumentary: Cool, pale, diaphoretic. Cardiovascular: Heart rhythm regular. Normal S1 and S2. II/VI holosystolic murmur appreciated at the left sternal border. Pulses 2+ all extremities. Respiratory: Crackles in the bases bilaterally. Gastrointestinal: Abdomen non-tender, non-distended. Neurological: Alert and oriented. Restless. Complete the sentence: The nurse is concerned that the patient may be experiencing ____ as evidenced by ____.

Correct answer: Acute coronary syndrome; radiating chest pain. The nurse recognizes the patient is most likely experiencing acute coronary syndrome due to the characteristic of the presenting chest pain. The patient is unlikely to be experiencing atrial fibrillation because the heart rhythm is regular. Acute coronary syndrome is more likely than a pulmonary embolism because of the presentation of the chest pain. Chest pain from a pulmonary embolism is usually pleuritic and does not radiate to the shoulder. Diaphoresis and tachycardia are non-specific symptoms that occur in response to physiological stress. While these symptoms indicate the severity of the patient's status, they do not definitively lead the nurse to concerns for acute coronary syndrome. Diaphoresis and tachycardia could be present in acute coronary syndrome, atrial fibrillation, and pulmonary embolism.

The nurse cares for the patient in the ED. 1903: Reviewed electrocardiogram (EKG). Shows ST segment elevation greater than 0.2 mV in leads V1 to V4. 1905: Called to patient’s room by spouse. Patient lying in gurney appears to be in distress and struggling to breathe. Reports “I cannot get air.” Requires pauses between words. RR 30/min. The nurse reviews the nurse’s note and plans care for the patient. The nurse anticipates taking which action? (Select all that apply.) 1. Obtain oxygen saturation. 2. Position the patient on the left side. 3. Auscultate lung sounds. 4. Administer PO furosemide. 5. Provide supplemental oxygen. 6. Prepare for percutaneous intervention. 7. Administer IV morphine. 8. Administer sublingual nitroglycerin.

Correct answer: 1, 3, 5, 6, 7, and 8. Because the patient now has severe dyspnea at rest the nurse should immediately obtain an oxygen saturation, auscultate lung sounds, and provide supplemental oxygen for hypoxia. Percutaneous intervention is indicated for this patient with EKG findings consistent with an ST-elevation myocardial infarction (STEMI). Percutaneous intervention should be expeditiously pursued while simultaneously providing treatment for the patient's shortness of breath. Providing morphine and nitroglycerin are indicated to reduce the chest pain and the shortness of breath, by reducing preload and pulmonary congestion. High Fowler is the best position for this patient due to the dyspnea; the patient should not be positioned on the left side. Furosemide could be indicated if the patient is experiencing pulmonary edema as the cause of the shortness of breath, but it should be administered IV.

Patient undergoes percutaneous coronary intervention with stent placement to the left anterior descending artery (LAD). The patient receives IV nitroprusside and IV dobutamine after the procedure. Complete the sentence by choosing three responses. Each choice will only be used once. The nurse monitors the patient receiving IV nitroprusside for potential non-therapeutic effects of the medication including ____, __, and ____. Choices: Dizziness. Headache. Hypotension. Coronary dissection. Hemorrhage. Thrombocytopenia. Venous thrombosis.

Correct answer: Dizziness, headache, and hypotension. Dizziness, hypotension, and headache can occur while receiving nitroprusside due to vasodilation. Coronary dissection and hemorrhage are both complications of percutaneous coronary intervention, but not concerns related to nitroprusside. Thrombocytopenia and venous thrombosis are not adverse effects of nitroprusside.

Following percutaneous coronary intervention with stent placement to the LAD, two days later the nurse prepares the patient for discharge. Which 3 patient findings indicate the patient’s condition has improved? 1. Blood pressure 138/86 mmHg. 2. Skin is cold and clammy. 3. Patient appears anxious and restless. 4. Two hour urine output total 40 mL. 5. Oxygenation saturation 97% (room air). 6. Ambulating in halls without dyspnea.

Correct answer: 1, 5, and 6. The patient's decreased blood pressure, increased oxygenation saturation, and ability to ambulate without shortness of breath all indicate improvements in the patient's condition. Cold and clammy skin indicates continued inadequate tissue perfusion. Increased anxiety and restlessness indicates hypoxia or pain. A urine output of 20 mL per hour indicates decreased renal perfusion.

The nurse cares for a middle-age adult patient on the neurosurgical unit. The patient presents with a gradual onset of a neck ache, which has progressed to neck pain and muscle spasms. The patient's symptoms began after a rear-end motor vehicle accident 4 months ago. The patient has experienced decreased range of motion with continued pain and stiffness in the neck, radiating to the top of the shoulder and scapula region for the duration of the prior 3 months. The patient describes the pain as quite severe at times, often interrupting sleep. Intermittently, the patient has experienced pain in the right upper extremity with numbness and tingling in the digits. For the prior 12 weeks, the patient has received conservative treatment including rest, physical therapy, and immobilization with a cervical collar. Analgesic treatment has included nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and a short course of muscle relaxants. The patient has achieved minimal relief of pain or improvement in range of motion. The patient's exam shows an exaggerated curvature of the thoracic spine, unequal shoulder height and scapula height, and a negative straight-leg raise. There is tenderness of the cervical spine to palpation, reflexes are intact, and there is no motor weakness. Cervical magnetic resonance imaging (MRI) scan confirmed cervical disc herniation at the intervertebral level of C6–C7. Plan: Anterior discectomy with fusion (ACDF). The nurse reviews the patient history to prepare for care. Which of the patient’s signs and symptoms is a symptom of radiculopathy? 1. Exaggerated curvature of the thoracic spine. 2. Negative straight-leg raise. 3. Neck and shoulder pain with arm numbness. 4. Unequal shoulder and scapula height.

Correct answer: 3. Neck and shoulder pain with arm numbness. Radiating pain, numbness, tingling, and decreased strength and range of motion are symptoms of radiculopathy. These findings may be associated with “pinching” of the nerves at the root. Herniated discs can protrude and apply pressure against the spinal nerves emerging from the spinal column through the intervertebral foramen between adjacent vertebrae. The nurse is not most concerned with the patient's exaggerated curvature of the thoracic spine, a finding related to kyphosis often caused by poor posture and bone conditions such as osteoporosis. This is not a symptom of radiculopathy and is unrelated to herniation of a cervical disc. A straight-leg raise is performed when patients have low back pain. Pain radiating into the leg with this maneuver can indicate nerve root irritation from lumbar disc herniation, not cervical. Scoliosis is related to the thoracic and lumbar spine as an abnormal, lateral S-shaped curve. Clinical findings include unequal shoulder and scapula height; this is not associated with cervical disc herniation.

The nurse cares for a middle-age adult patient on the neurosurgical unit. The patient presents with a gradual onset of a neck ache, which has progressed to neck pain and muscle spasms. The patient's symptoms began after a rear-end motor vehicle accident 4 months ago. The patient has experienced decreased range of motion with continued pain and stiffness in the neck, radiating to the top of the shoulder and scapula region for the duration of the prior 3 months. The patient describes the pain as quite severe at times, often interrupting sleep. Intermittently, the patient has experienced pain in the right upper extremity with numbness and tingling in the digits. For the prior 12 weeks, the patient has received conservative treatment including rest, physical therapy, and immobilization with a cervical collar. Analgesic treatment has included nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and a short course of muscle relaxants. The patient has achieved minimal relief of pain or improvement in range of motion. The patient's exam shows an exaggerated curvature of the thoracic spine, unequal shoulder height and scapula height, and a negative straight-leg raise. There is tenderness of the cervical spine to palpation, reflexes are intact, and there is no motor weakness. Cervical magnetic resonance imaging (MRI) scan confirmed cervical disc herniation at the intervertebral level of C6–C7. Plan: Anterior discectomy with fusion (ACDF). Complete the sentence: The nurse recognizes herniated disc conditions result in ____ due to ____.

Correct answer: Nerve root compression; the disc bulging outward. A herniated disc is a condition in which the nucleus pulposus of the intervertebral disc bulges outward between adjacent vertebrae or ruptures with resultant nerve compression. The herniated disc “pinches” or compresses against the nerve causing radiculopathy. The nurse recognizes severe bone infection may be due to infecting microorganisms which can invade the bone or bone marrow directly through surgery, open wounds, or fractures. Severe bone infection is not related to cervical disc herniation. Inflammation of the joints are conditions usually associated with arthritis (e.g., osteoarthritis) which occur due to gradual loss of articular cartilage. This condition is unrelated to cervical disc herniation.

The patient with C6–C7 cervical disc herniation underwent anterior discectomy with fusion (ACDF). The patient returns to the unit from the Post-Anesthesia Care Unit (PACU). The nurse prioritizes assessment for which 3 potential postoperative complications? 1. Spinal cord edema. 2. Cauda equina syndrome. 3. Bradykinesia of motor movements. 4. Hematoma formation. 5. Ankylosis. 6. Recurrent laryngeal nerve injury.

Correct answer: 1, 4, and 6. The nurse identifies the patient is at an increased risk to develop postoperative complications of spinal cord edema, recurrent laryngeal nerve injury and hematoma formation. The nurse will place priority on assessing for the development of these complications. During the anterior approach discectomy the recurrent laryngeal nerve may become injured, leading to hoarseness, ineffective cough, and inability to clear pulmonary secretions. Bleeding at the surgical site may occur, with resultant hematoma formation, leading to excessive pressure in the neck, swelling, and pain. Spinal cord edema may result in respiratory difficulty and worsening upper and lower extremity weakness. The nurse does not identify the patient as an increased risk to develop cauda equina syndrome, bradykinesia of motor movements, or ankylosis. Cauda equina syndrome is a medical emergency in which multiple lumbar nerve root compressions, from tumor or herniated disc, may result in bladder and bowel incontinence, increased pain, and muscle weakness. Ankylosis, joint stiffness and fixation of a joint, usually is significant in patients with chronic joint inflammation and destruction (i.e., rheumatoid arthritis). Bradykinesia of motor movements, is usually associated with patients with Parkinson disease (PD).

The patient with C6–C7 cervical disc herniation underwent anterior discectomy with fusion (ACDF). Complete the sentence using three different choices: The nursing goals include that the patient will ____, __, and ____. Choices: Maintain respiratory function. Preserve bladder tone. Improve mobility. Achieve pain relief. Have no muscle rigidity. Not develop joint contractures.

Correct answer: Maintain respiratory function; achieve pain relief; improve mobility. The nursing goals for the postoperative plan of care include that the patient will maintain respiratory function, improve mobility, and achieve pain relief. Respiratory function may become impaired because injury to the recurrent laryngeal nerve may result in hoarseness, inability to cough and clear lung secretions. The surgical regimen postoperatively may contribute to decreased neck range of motion because patients are often instructed to wear a cervical neck collar which limits neck motion. Patients should expect to have improvement in radicular pain as the nerve recovers. With a bone fusion, patients may experience more severe pain at the donor site, often the iliac crest, than at the surgical incision. The nursing goals for the postoperative plan of care do not include that the patient will be free of contractures, preserve bladder tone, and have no muscle rigidity. Loss of bladder tone or sphincter control may occur in patients with nerve damage from herniated lumbar discs who undergo surgical decompression. Muscle rigidity is not associated as a postoperative complication from cervical discectomy, but is a complication in patients who have conditions such as Parkinson disease. Joint contractures do not develop as a complication from cervical discectomy. These may develop as a consequence of various conditions, including paralysis and stroke.

The nurse provides postoperative care following anterior discectomy with fusion (ACDF) for C6–C7 cervical disc herniation. Complete the sentences: The nurse should ____. It would be a priority for the nurse to __. The nurse should maintain the patient’s neck ____.

Correct answer: Inspect the neck dressing for serosanguineous drainage. Report any impaired swallowing. In a neutral, midline position. The nurse should inspect the neck dressing for serosanguineous drainage. Bleeding may occur which increases pressure on the neck and incision. Serosanguineous drainage on the neck dressing may indicate a dural leak, or an opening in the the outermost layer of the spinal covering. This is a serious condition which should be reported to the physician. A positive straight leg raise, pain radiating down the sciatica when the leg is raised, is a clinical finding associated with low back pain and potentially lumbar disc disease. Hypotension and tachycardia are not expected findings postoperatively. The occurrence of these can indicate deterioration of the cardiovascular status, bleeding, and poor circulation to the surgical site. It would be a priority for the nurse to report any impaired swallowing. Neurologic checks for difficulty swallowing and upper and lower extremity weakness are done postoperatively because spinal cord compression can result in rapid or delayed onset of paralysis. The patient should use a cervical collar, not thoracolumbar brace, with activity, which provides neck immobilization and stability to the neck. Transient edema of the operative site and injury to the recurrent laryngeal nerve may result in a sore throat and hoarseness. The nurse should encourage voice rest, not speaking and frequent voice use, in addition to throat lozenges, and humidification. The nurse should maintain the patient’s neck in a neutral, midline position. Postoperatively, the patient wears a cervical collar and keeps the neck in a midline position. This position maintains proper alignment of the head and neck. Postoperatively, the neck is not maintained in a flexed position, lowered with chin towards the chest, or extended, tilted with the chin lifted upwards.

The nurse provides care on the 2nd postoperative day following anterior discectomy with fusion (ACDF) for C6–C7 cervical disc herniation. Which finding indicates the patient is progressing as expected? (Select all that apply.) 1. The patient’s blood pressure is 128/80 mmHg and the pulse is 88/min. 2. Light pink drainage is present on the neck dressing. 3. The patient has thick, clear secretions and a weak cough. 4. The neck and thorax are being supported when the patient is assisted to a sitting position. 5. The patient is tolerating a pureed diet. 6. The patient reports a headache, 6/10 pain scale. 7. The patient has bilateral, equal, 5/5 strength in the upper extremities.

Correct answer: 1, 4, 5, and 7. Findings which indicate the patient is progressing as expected include the patient’s blood pressure is 128/80 mmHg and the pulse is 88/min. Postoperatively, blood pressure greater than 90 mmHg and less than 160 mmHg, and the pulse between 60/min and 120/min are acceptable adult assessment findings, indicating cardiovascular stability. The patient's neck and thorax are being supported when the patient is assisted to a sitting position is an expected finding. The neck should be maintained in a neutral, midline position, and when position changes are made, the head, neck, and thorax should be kept aligned. A sore throat may be expected following an anterior cervical discectomy due to temporary edema. Throat lozenges and humidification may relieve the patient's discomfort. The patient has bilateral, equal, 5/5 strength in the upper extremities, which indicates the absence of neurologic deficits from spinal cord compression. Findings which do not indicate the patient is progressing as expected include light pink drainage being present on the neck dressing. Serosanguineous drainage on the neck dressing can suggest a dural leak; this finding should be reported. Meningitis may occur following a dural leak. Any headache should be thoroughly assessed and reported, including the patient’s headache, 6/10 pain scale. The presence of a weak cough and thick, clear secretions can indicate potential respiratory difficulties. Injury to the recurrent laryngeal nerve may result in not only hoarseness, but a poor cough and inability to clear pulmonary secretions. Correct answer: 1, 2, 3, and 5.

The nurse delivers a change-of-shift report. Which information is important for the nurse to include in the report? (Select all that apply.) 1. Patient’s admitting diagnosis and relevant history. 2. Patient’s emotional response to condition. 3. Current IV solution and flow rate. 4. Description of routine morning care provided. 5. Use of and response to as needed medications.

Rationales: 1. The patient’s admitting diagnosis should be included. Any relevant medical history is also included. 2. The patient’s emotional response to the condition should be included. 3. The current IV solution and flow rate, when the current bag is scheduled to be completed, and the amount of solution remaining to be infused should be included. 4. Descriptions of routines (in this case, routine morning care) or normal findings should not be included. 5. The use of and response to as needed medications should be included. Think Like a Nurse: A hand-off report must include the most relevant information for the next shift nurse to safely begin care, while also being concise. A common way to organize report is using the SBAR acronym: • Situation: Name, room, age, gender. • Background: Admission diagnosis, pertinent medical history. • Assessment: Code status, abnormal vital signs, IV site/fluid/rate, other abnormal assessments, current pain score, safety needs. • Recommendation: Pending labs/reports, needed changes in care, concerns for the new shift, discharge planning. The hand-off report is completed in the presence of the patient whenever possible so the patient is aware of all aspects of the plan of care. Be sure to maintain privacy so that the report is not heard by other patients or uninvolved staff members. Speak in low voices or out-of-hearing range of others. Content Refresher: The change-of-shift report provides a structured exchange of information and allows the oncoming nurse to provide continuity of care. A change-of-shift report should include: • Actual or potential patient needs. • How needs have been met so far. • Lab or diagnostic test results. • Needed nursing treatments or activities. • Recent changes to the medical plan such as medications or procedures. Do not include in change-of-shift report: • Routine care needs unless modified from standards. • Rumors/gossip. • Opinions/value judgments about patient or family. • Patient information that is

The nurse provides care for a patient who receives frequent opioid analgesics for pain. The patient’s spouse states to the nurse, “I think my spouse is receiving too many pain medications. Next time, please administer a placebo.” Which action by the nurse is best? 1. Inform the patient of the spouse’s request. 2. Administer a placebo instead of the narcotic. 3. Inform the spouse that the action is unethical. 4. Notify the health care provider immediately.

Correct answer: 3. Inform the spouse that the action is unethical. Rationales: 1. The nurse should avoid creating conflicts if possible. 2. The nurse has a duty to be truthful with the patient. 3. The nurse has an ethical and legal duty to protect the competent patient’s rights. The nurse also has a duty to advocate for the patient before the wishes of the spouse. In this case, the patient has a right to receive prescribed medications without outside interference if the patient reports pain. 4. The nurse can resolve the issue, so there is no need to notify the health care provider at this time. Think Like a Nurse: Your priority in this situation is to best meet the needs of the patient before meeting the spouse’s needs. The patient is experiencing pain and has the right to expect to have the pain assessed and treated. If a patient's spouse is asking for a placebo, then the next course of action would be to explore the spouse’s concerns and explain how the use of placebo in this instance would be unethical. Placebos have a place in health care, but it is beyond your scope of practice to provide a placebo without authorization from the health care provider. Content Refresher: Nurses are advocates and provide a liaison between patients, health care providers, family members, and others. Nurses advocate for patients by helping them understand their diagnoses and then make the best health care decisions. Because every patient's beliefs, circumstances, and preferences are different, it is not uncommon for their wishes to conflict with health care providers’ prescriptions and sometimes their family’s wishes. Understand and support the patient's rights. Be knowledgeable about and involved in all aspects of the patient's care and have a positive working relationship with other team members. Act as a communicator, liaison, educator, interpreter, and caregiver.

The clinic nurse prepares to provide instructions for follow-up to a patient based on laboratory results. Which method is most appropriate for delivering these instructions? 1. Leave a note in the medical record to flag the task for the next visit. 2. Use the facility-approved patient portal to send an encrypted message. 3. Send the patient an email using the clinic’s email address. 4. Text the patient information using a clinic-issued smartphone.

Correct answer: 2. Use the facility-approved patient portal to send an encrypted message. 1) INCORRECT -As the instructions are for follow-up, the information needs to be provided in a more immediate manner. 2) CORRECT - Electronic communications with patients must be encrypted for protection of patient privacy and confidentiality. 3) INCORRECT - Using email to communicate with patients is permissible, but the email system must be secure to protect patient confidentiality. 4) INCORRECT - While a text message may allow for quick communication, the method must allow for encryption to ensure protection of patient confidentiality.

The nurse plans a presentation to discuss the concept of malpractice. The nurse covers which element required to be present in a malpractice case? (Select all that apply.) 1. Intention. 2. Injury. 3. Causation. 4. Duty. 5. Breach of duty.

Correct answer: 2, 3, 4, and 5. Rationales: 1. Intention is not one of the four required elements in malpractice cases. 2. Injury is one of the four required elements in malpractice cases. 3. Causation (nurse conduct causes injury) is one of the four required elements in malpractice cases. 4. Duty (legal relationship between nurse and patient) is one of the four required elements in malpractice cases. 5. Breach of duty is one of the four required elements in malpractice cases. Think Like a Nurse: Malpractice occurs when a nurse fails to act as a competent nurse normally would act in the same situation and this results in patient injury. It results in harm from being careless, not from intentionally harming a patient (which is assault and battery). Examples of malpractice include: • Failing to act in an emergency. • Incorrect use of equipment. • Inappropriate medication administration. Content Refresher: Malpractice is a type of negligence done by a professional who fails to provide services that follow the standards of the profession. Negligence, in the law, results in harm from carelessness rather than intent. Acts of negligence include carelessness, delivery of substandard patient care, or failure to adhere to standards of care. To prevent malpractice: • Review agency policy for unfamiliar procedures. • Seek guidance when needed for new interventions. • Maintain knowledge of current practice guidelines for safe care. An example of nursing malpractice would be failing to call for the code team in response to a patient who demonstrates agonal respirations or administering digoxin to a patient whose heart rate is 48 beats per minute.

While providing for a patient of Russian descent, the nurse overhears the health care provider obtaining consent for a procedure. The nurse knows the patient does not speak English well enough to give consent. Which action should the nurse take? 1. Ask a co-worker who speaks Russian to interpret for the health care provider. 2. Wait for the hospital interpreter to translate for the health care provider. 3. Obtain consent over the phone from a relative of the patient who speaks English. 4. Allow the patient to give consent after talking to the health care provider.

Correct answer: 2. Wait for the hospital interpreter to translate for the health care provider. 1) INCORRECT - Only approved hospital interpreters may be used to translate information to a patient. It is not appropriate for a co-worker who speaks the patient's language to translate unless certified by the hospital to do so. 2) CORRECT - This is the best course of action for the nurse to take to resolve a potential ethical dilemma and advocate for the patient. Waiting for an approved hospital interpreter is the appropriate course of action. It is important the patient fully understands all aspects of the procedure and is given an opportunity to ask questions to make a well-informed decision. 3) INCORRECT - Consent must be obtained appropriately. Obtaining consent for the patient from a relative over the phone is not appropriate. If the patient was unable to give consent due to medical illness, the “power of attorney” would be the only person acceptable to consent on the patient's behalf. 4) INCORRECT - Doing nothing would not be an appropriate course of action for the nurse in this scenario. It is the nurse’s responsibility to advocate for the patient. A lack of action from the nurse in this situation would be an act of ethical injustice for the patient.

The nurse in the outpatient gastroenterology clinic provides care for a middle-age adult patient. The patient presents in the clinic for follow-up of persistent lower gastrointestinal symptoms. The patient has recent, unintentional weight loss with abdominal pain, distention, and diarrhea. The patient is experiencing flatulence, steatorrhea, and bloating after eating. A recent colonoscopy with biopsy was normal. The patient is notably fatigued, accompanied by findings of glossitis and skin pallor. The patient also reports depression, lack of focus, migraine headaches, and at times paresthesias in the hands and feet. The patient has joint pain and imaging evidence of decreased bone density. Medications include an antidiarrheal agent, oral ferrous sulfate, calcium and vitamin D supplements, and levothyroxine. Follow-up hematology and blood chemistries results are pending. Past Health History: Two years ago, the patient developed a thyroid goiter and was diagnosed with Hashimoto thyroiditis. Past medical history includes gastroesophageal reflux disease (GERD), chronic anemia, osteopenia, and obstructive sleep apnea (OSA). Plan: Serologic antibody testing and upper gastrointestinal endoscopy with intestinal biopsy. The nurse reviews the patient’s history. Which 3 patient findings are most concerning to the nurse? 1. Unintentional weight loss. 2. History of thyroiditis. 3. Decreased bone density. 4. Steatorrhea. 5. Abdominal pain and distention. 6. Skin pallor. 7. Migraine headaches.

Correct answer: 1, 4, and 5. The nurse is most concerned with patient findings of unintentional weight loss, steatorrhea, and abdominal pain and distention. Impaired absorption of fats, carbohydrates, proteins, vitamins, and minerals can result in these findings. The nurse is not as concerned with the patient finding iron-deficiency anemia or osteopenia. The patient's anemia is evidenced by skin pallor, but the patient is taking oral ferrous sulfate as therapy and has pending follow-up hematology labs. The patient's osteopenia is evidenced by decreased bone density, for which the patient has supplemental intake of calcium and vitamin D. The patient's anemia and osteopenia findings may be related to the primary concern of malabsorption due to impaired absorption of minerals and vitamins. The patient's history of GERD and migraine headaches are more chronic findings, and the nurse is concerned with the patient's acute findings. The patient's history of thyroiditis is more significant.

The nurse in the outpatient gastroenterology clinic provides care for a middle-age adult patient. The patient presents in the clinic for follow-up of persistent lower gastrointestinal symptoms. The patient has recent, unintentional weight loss with abdominal pain, distention, and diarrhea. The patient is experiencing flatulence, steatorrhea, and bloating after eating. A recent colonoscopy with biopsy was normal. The patient is notably fatigued, accompanied by findings of glossitis and skin pallor. The patient also reports depression, lack of focus, migraine headaches, and at times paresthesias in the hands and feet. The patient has joint pain and imaging evidence of decreased bone density. Medications include an antidiarrheal agent, oral ferrous sulfate, calcium and vitamin D supplements, and levothyroxine. Follow-up hematology and blood chemistries results are pending. Past Health History: Two years ago, the patient developed a thyroid goiter and was diagnosed with Hashimoto thyroiditis. Past medical history includes gastroesophageal reflux disease (GERD), chronic anemia, osteopenia, and obstructive sleep apnea (OSA). Plan: Serologic antibody testing and upper gastrointestinal endoscopy with intestinal biopsy. Complete the sentences: The nurse determines the patient findings are consistent with the intestinal disorder ____. The nurse identifies symptoms occur due to an autoimmune response triggered by __. The nurse recognizes that this disorder may be associated with the patient’s history of ____.

Correct answer: Celiac disease; consuming gluten; Hashimoto thyroiditis. The nurse identifies the patient findings most closely with the intestinal disorder celiac disease. The most common symptoms of celiac disease are odorous diarrhea, abdominal pain, distention, flatulence, steatorrhea, and weight loss. Common symptoms of diverticulitis include acute left lower abdominal pain, nausea and vomiting, and signs of systemic infection. Ulcerative colitis is usually characterized by bloody diarrhea and abdominal pain. The nurse identifies symptoms occur due to an autoimmune response triggered by consuming gluten. Celiac disease develops in genetically predisposed patients who exhibit an immune response in the small intestine to gluten products. Celiac disease is not triggered by environmental factors (e.g., smoking, stress, or H. pylori). The nurse recognizes that celiac disease may be associated with Hashimoto thyroiditis. This immune system reaction damages the thyroid and increases the risk for other autoimmune diseases. Patients with one autoimmune disease are vulnerable to develop another autoimmune disorder. Celiac disease is not associated with gastroesophageal reflux disease and obstructive sleep apnea.

The patient presented with unintentional weight loss, abdominal pain, distention, diarrhea, steatorrhea, and bloating after eating, and has a history of Hashimoto thyroiditis. The nurse provides care 2 weeks later during a follow-up clinic visit. The patient’s diagnostic tests confirm a diagnosis of celiac disease. The nurse’s priority consideration is the patient’s increased risk to develop which autoimmune disease? 1. Guillain-Barré syndrome (GBS). 2. Type 1 diabetes. 3. Atopic dermatitis (eczema). 4. Dressler syndrome.

Correct answer: 2. Type 1 diabetes. The nurse’s priority consideration is the patient's increased risk to develop type 1 diabetes if celiac disease is not treated. Celiac disease is associated with an increased risk to develop autoimmune diseases, including type 1 diabetes, rheumatoid arthritis, and thyroid disease. Patients who have one autoimmune disease are at risk to develop other autoimmune diseases. Type 1 diabetes and celiac disease are recognized as related autoimmune disorders due to a shared common genetic background. The nurse’s priority consideration for the patient is not an increased risk to develop Guillain-Barré syndrome, Dressler syndrome, or atopic dermatitis. Considered an autoimmune reaction to necrotic heart muscle, Dressler syndrome occurs following myocardial infarction. Atopic dermatitis is an inherited hypersensitivity skin reaction to environmental allergens. Guillain-Barré syndrome is caused by cellular and humoral immune responses that damage the myelin nerve sheath following a viral or bacterial infection. These are not typical autoimmune disease associations in patients who have celiac disease.

The nurse plans patient education about celiac disease. For each nursing statement, specify whether the statement is indicated or not indicated for the patient’s care. Each statement must have one response. 1. “You’ll need to avoid consuming wheat, barley, and rye products.” 2. “Most non-food products and medications will be gluten-free.” 3. “Removing dietary gluten will resolve your symptoms immediately.” 4. “Some gluten-free foods can be cross-contaminated with wheat products when being prepared.” 5. “Report symptoms of increased urination, weight loss, and thirst.”

Correct answer: 1. Indicated. 2. Not indicated. 3. Not indicated. 4. Indicated. 5. Indicated. The nurse teaches that prolamins, storage proteins, known as gluten, in wheat, barley and rye should be avoided. Oat grains are gluten-free but may be produced in facilities where cross-contamination with wheat may occur. The nurse encourages self-advocacy about strict adherence to a gluten-free diet, teaching that gluten-free foods can be cross-contaminated with wheat during preparation. Teaching about signs and symptoms of diabetes is recommended with a diagnosis of celiac disease due to a shared genetic background of these autoimmune diseases. These symptoms include increased urination, thirst, and weight loss. The nurse does not teach that most non-food products and medications will be gluten-free. These include over-the-counter medications and some lipsticks and toothpastes. The nurse teaches that removing dietary gluten may take a year to resolve symptoms, indicating the integrity of the small intestine villi has been restored.

The nurse provides patient education about foods containing gluten. For each description of gluten sources, specify the potential food choices that would be appropriate for the patient. Each description may support more than one potential food choice. Each section must have at least one choice selected. Naturally gluten-free foods: Nut flours. Malt and malt flavoring. Potatoes. Foods to avoid: Baked goods and breads. Quinoa. Dairy products. Foods that may contain gluten: Beans and legumes. Processed lunch meats. Corn.

Correct answer: Naturally gluten-free foods: Nut flours and potatoes. Foods to avoid: Baked goods and breads. Foods that may contain gluten: Processed lunch meats. The nurse teaches food choices that are naturally gluten-free include nut flours and potatoes. Malt and malt flavoring used as enhancements in foods may contain gluten; the patient should read the food label to determine if the product contains malt or malt extract. The nurse teaches food choices to avoid because of containing gluten are baked goods and breads (e.g., cakes, pastries, cookies, breads, pastas, and crackers). Quinoa is an acceptable, gluten-free grain to consume. Dairy products are naturally gluten-free. The nurse teaches food choices that may contain gluten, requiring careful reading of labels, include processed lunch meats. These products may contain wheat, barley, or rye. Beans, legumes, and corn food choices are appropriate gluten-free foods for the patient to consume.

The nurse evaluates the patient during a clinic follow-up visit 3 months after the celiac diagnosis. Which 2 patient findings indicate the patient is progressing as expected? 1. Patient reports feeling frustrated about “not being able to eat my favorite foods.” 2. The patient has had a weight gain of 5 lb (2.26 kg). 3. Patient reports intermittent abdominal bloating after eating. 4. The patient denies frequent urination and thirst. 5. The patient reports limiting milk, cheese, and eggs in the diet.

Correct answer: 2 and 4. Patient findings indicating the patient is progressing as expected are increased body mass index (BMI) showing weight gain of 5 lb (2.26 kg), an improvement from the prior assessment, which showed the patient with weight loss. The patient denies frequent urination and thirst, symptoms that may indicate the development of diabetes. Patients with celiac disease should be cognizant of symptoms of type 1 diabetes due to a shared genetic background found in a specific human leukocyte antigen (HLA) genotype. The patient's bone mineral density measurement shows no change in the T-score. The patient’s osteopenia has shown no progression to osteoporosis as detected by this measurement. The patient's skin is pink, and tongue findings show an improvement from the prior assessment, indicating possible better iron absorption and correction of anemia. Patient findings that do not indicate the patient is progressing as expected are the patient's frustration with abstaining from favorite foods and the patient feeling that it is extra trouble to ask about gluten-free foods in restaurants. Celiac disease requires lifestyle adaptation and new coping skills. The nurse may recommend a dietitian consult and guidance from support groups to maintain gluten-free adherence and an asymptomatic state. The patient shows continuing malabsorption symptoms of abdominal bloating after eating and weekly episodes of diarrhea. The nurse should advise the patient it may take up to a year for the intestinal changes from gluten consumption to heal. The nurse should reteach principles of maintaining a gluten-free lifestyle.