Adult/Family Health III Exam 1 Case Studies

(CHAPTER 69) 4. The nurse monitors Mary for which symptoms related to the status of AWS? (select all that apply) A. vital signs B. CIWA-Ar score C. CAGE score D. mental status E. respiratory status

A, B, D, and E - The CAGE (option C) is a tool to assess for the presence of alcohol use or an alcohol use disorder. The CAGE would ideally be completed at the time of admission or at least before signs of AWS start to appear.

(CHAPTER 2) 5. Excellent interprofessional collaboration in Mr. Garfield's care is evidenced by which of the following statements? A. all members of the team worked according to their speciality to determine an appropriate discharge plan. B. only the team members necessary were involved in designing Mr. Garfield's discharge plan. C. only the inpatient team as necessary in developing the discharge plan. D. only the outpatient team was necessary in developing the discharge plan.

A - All members of the team work together according to their specialty.

(CHAPTER 4) 2. In checking for the presence of a living will for Mr. Michaels, the nurse is using which ethical principle? A. autonomy B. beneficence C. justice D. nonmaleficence

A - Autonomy examines the individual's personal right to make decisions concerning themselves. beneficence asks the question of who benefits from th action(s) taken by others. Veracity is the requirement to tell the truth. It also requires that intentional misleading or deception of the patient to influence decisions is not done. Justice examines who will be vulnerable in any actions taken.

(CHAPTER 3) 4. What type of exercise should the nurse recommend for Mrs. Estrada? A. encourage her to continue doing light housekeeping duties and taking walks with the children every day. B. encourage her to dance for 30 minutes each day to fast-paced Cuban music. C. encourage her to jog at least three times a week until she can jog eight to ten blocks. D. have her procure a membership in a gym with a personal trainer.

A - Light daily exercise is feasible and consistent with older adult Cuban women. A long-term exercise program with family input will help ensure a continuation of the exercise program and something with which she is familiar. She may not be able to or have the desire to jog or do fast-paced dancing for 30 minutes each day. Older adult Cuban women do not usually go to a gym, plus the cost of a membership and personal trainer may be more costly than she can afford.

(CHAPTER 4) 3. As Mr. Michaels' level of consciousness improves and he is following commands, what must be evaluated prior to making the decision about placement of the gastrostomy tube? A. mental competency B. swallowing C. psychomotor abilities D. vision and hearing screening

A - Patients have a right to refuse or accept life sustaining treatment, and the only issue is to determine whether the patient is mentally competent to make that decision. Because Mr. Michael's is becoming more responsive and following some commands, his mental competency must be determined.

(CHAPTER 4) 5. As a result of the difference between the family members' and Mr. Michaels' wishes, the nurse should request which consultation? A. ethics committee B. interprofessional meeting C. hospital chaplain D. family lawyer

A - This is an example of an ethical dilemma and should be referred to the ethics committee. It is not a decision for the health-care team guiding the patient's care, the hospital chaplain, or the family lawyer.

(CHAPTER 6) 5. Which of these assessment findings will alert the nurse to possible worsening of heart failure? (select all that apply) A. sudden inability to breathe while laying flat B. blurred vision C. craving for sweets D. loose bowel movements E. a weight gain of 2.5 pounds in one day

A and E - Shortness of breath and weight gain are indicators of an exacerbation of heart failure.

(CHAPTER 2) 2. Which members of the interprofessional home-care team are necessary for Mr. Garfield's care? (select all that apply) A. home care nurse B. home health aide C. speech language pathologist D. primary care provider E. palliative care provider

A, B, C, D and E - All members of the team help plan care.

(CHAPTER 69) 3. The nurse caring for Mary incorporates which nursing diagnosis into the plan of care? (select all that apply) A. alteration in comfort: discomfort r/t withdrawal B. potential for injury r/t withdrawal C. anxiety r/t the distress of withdrawal D. imbalanced nutrition: less than body requirement E. dysfunctional family process

A, B, C, and D - In Mary's case, there is not enough evidence to support a diagnosis of dysfunctional family processes. Mary's use of alcohol has caused disruption to the family by decreasing the amount of time spent with her family. However, her family has demonstrated interest and support. For this family there is evidence of knowledge deficit, as evidenced by the lack of knowledge about alcohol use disorders and the role of the family in recovery and relapse prevention.

(CHAPTER 69) 5. The nurse includes which of the following information in Mary's teaching plan? (select all that apply) A. how to cope with triggers and cravings B. importance of good nutrition C. substance abuse treatment options D. how much alcohol is acceptable to drink E. importance on building a support network

A, B, C, and E - How much alcohol is acceptable to drink? No alcohol is acceptable.

(CHAPTER 6) 2. The nurse monitors Ms. Gomez for the development of cognitive issues. Which clinical manifestations are early indications of the development of dementia? (select all that apply) A. short-term memory impairment B. acute onset of reduced awareness C. gradual onset of impaired judgement D. fluctuating levels of alertness E. personality changes

A, C, and E - Dementia has a gradual onset, typically has short and intermediate memory loss, and is associated with personality changes.

(CHAPTER 69) Ms. Mary Litfield is a 64-year-old widowed female who is admitted on Monday to the surgical service of a general hospital for resection of colon cancer. Her operation is very successful, but on Wednesday, when she is about to be transferred from the step-down unit to a regular surgical bed, there is a change in her condition. She becomes confused, anxious, and tremulous. Her pulse and blood pressure are elevated, and she seems to be responding to visual hallucinations. Her surgical team initially suspects pneumonia or a postoperative infection, but her temperature and white blood cell count are both normal and her abdomen is soft. Radiographic examination of her chest and abdomen shows no new problems. Abdominal ultrasonography shows a fatty liver. Mary's nurse suspects alcohol withdrawal and calls her family to obtain more information. Mary's daughter tells the nurse that she has been worried about Mary's drinking. The death of her husband 2 years ago was very hard on her, but his life insurance provided enough money for her to take early retirement from her job as a high school English teacher. She has been spending a lot of time alone at home, not going out with her old friends, seems less interested in her two young grandchildren, and is sometimes irritable with them. Mary and her husband used to enjoy one or two cocktails together in the evenings, but her daughter expresses concern that her drinking may have increased. Mary is given a diagnosis of delirium tremens, an AWS characterized by global confusion, autonomic hyperactivity, and hallucinations. The nurse assesses Mary's AWS using the CIWA-Ar, a tool that assess the presence and severity of AWS. On the basis of a total score of 20, she contacts the nurse practitioner working with Mary's team. Mary is given lorazepam (Ativan) 2 mg intramuscularly immediately and monitored every hour for 4 hours. After 4 hours, Mary is less confused and less tremulous. Monitoring of Mary's status is ongoing. The CIWA-Ar is repeated every 4 hours. Lorazepam 2 mg PO is ordered every 4 hours for a CIWA-Ar score between 10 and 19. Lorazepam is discontinued when the CIWA-Ar score is less than 10. Her stay in the hospital is prolonged by 3 days, 2 of which are spent in the step-down unit. Her vital signs stabilize, and she becomes more coherent. On her final day in the hospital, the nurse who spoke to her family goes to check on her. Mary acknowledges that she has been drinking more since retirement and the death of her husband. She is skeptical of the idea that her hospital complications have been caused by alcohol withdrawal because "nothing like this has ever happened to me before". She denies having a drinking problem and insists that she can abstain for as long as necessary if it is required. Mary's daughter comes to pick her up and asks the nurse to "do something" because she is worried about Mary's ability to recover from the surgery and do the necessary follow-up if her drinking continues. The nurse asks to meet with Mary and her daughter to discuss ongoing treatment, but Mary is packed up and leaves the hospital before the meeting can take place. At her daughter's urging, Mary abstains from alcohol for several weeks and makes a successful recovery from her surgery; but 2 months later, she is back in the hospital with a broken hip, sustained in a fall down her basement stairs. She spends a day in the ED waiting for a bed, and when she returns to the unit, she is already tremulous and hallucinating. The nurse makes the diagnoses of -- potential for injury related to alcohol withdrawal and alteration in sensory perception (visual hallucinations) related to alcohol withdrawal Mary is again assessed using the CIWA-Ar and is treated with lorazepam. The nurse monitors her vital signs at frequent intervals and uses the CIWA-Ar to assess withdrawal symptoms and response to the medication. She implements seizure and fall precautions. Mary has IV fluids running and is receiving a multivitamin, folic acid, and thiamine. The nurse is providing a calm, quiet, and supportive environment. She provides reality orientation as needed. Mary begins to improve significantly the second day. Her hip replacement surgery goes well, and she is beginning to bear weight again. The nurse now believes it to be a good time to start educating Mary about her alcohol-related disorders and recovery planning. The nurse understands that simply treating the withdrawal is not enough and that Mary needs ongoing treatment to address her AUD. She asks the provider to get a substance use treatment referral from social work. Mary is visited by her daughter, son-in-law, and her granddaughter and by an old friend of hers who has been in recovery for many years. Mary attends an AA group that meets in the hospital and is expressing interest in starting substance abuse treatment after she is discharged. 1. During Mary's first admission, prior to transferring her from the step-down unit, the nurse observes symptoms of AWS. On the basis of her length of time in the hospital and Mary's symptoms, the nurse knows Mary's symptoms indicate which stage of AWS? A. severe AWS B. moderate AWS C. mild AWS D. early AWS

B - Hallucinations are not usually experienced in early to mild; the symptoms occur in the moderate stage. Without intervention, the risk increases for a grand mal (generalized tonic-clonic) seizure.

(CHAPTER 2) 4. Which statement is incorrect about working with a patient who primarily speaks a different language? A. an interpreter is always advised when imparting important information. B. family members can be used to interpret when necessary. C. written teaching materials should be in the patient's native language. D. non-english speaking patients require advance discharge planning

B - It is not advisable to use family members as interpreters as they may only impart the information they understand or are comfortable with the patient knowing.

(CHAPTER 68) 3. Ms. Wiley wants to know the key difference between the Roux-en-Y and adjustable gastric banding. Which explanation by the nurse is most accurate? A. "some surgeons just prefer one over the other" B. "Roux-en-Y is a combination of restrictive surgery and a malabsorptive surgery" C. "adjustable gastric banding is designed to be temporary" D. "Roux-en-Y is a type of adjustable gastric banding"

B - Roux-en-Y is a combination of a restrictive surgery and a malabsorptive surgery. While A is true, it does not factually answer the patient's question.

(CHAPTER 3) Mrs. Maricela Estrada is a 63-year-old Cuban who seeks consultation at a clinic because of her weakness, lethargy, and fatigue that she has been experiencing for 2 months. A week ago while cooking dinner a her daughter Carmen's house, she momentarily lost her balance and slipped on the kitchen floor. Although Mrs. Estrada sustained only a mild bruise on her leg, her daughter insisted on taking her to the clinic for a checkup because of her persistent symptoms. Mrs. Estrada, widowed 4 years ago when her husband died of an aortic aneurysm, lives with Carmen, aged 40. Carmen is divorced and has three children: Fernando, aged 15; Mariana, aged 10; and Louisa, aged 7. Since moving into Carmen's house, Mrs. Estrada has been managing the household while Carmen is at work. Mrs. Estrada prepares the family's meals, attends to the children when they come home from school, and performs light housekeeping chores. Mrs. Estrada, who does not speak English, converses with her daughter and grandchildren in Spanishs.Although the children and their mother occasionally speak English among themselves, the family's language at home is Spanish. At the clinic, Mrs. Estrada is diagnosed with essential hypertension and non-insulin dependent diabetes mellitus. The nurse practitioner prescribes an oral hypoglycemic medication and advises her to exercise daily and to limit her food intake to 1,500 calories a day. Mrs. Estrada is concerned because she usually prepares traditional Cuban meals and is not sure whether she can tolerate being on a diet. Besides, she explains to the nurse, the dishes she prepares are very "healthy". Proof of that, she states, is that her three grandchildren are plump and nice-looking. Mrs. Estrada tells the nurse that instead of buying the prescribed medicine perhaps she will go to the botanica (Hispanic herbal pharmacy) and obtain some herbs that will help lower her blood sugar. She also told the nurse that she would be seeing a curandero, a traditional healer for further advice. The provider requests that Mrs. Estrada return to the clinici in 1 month for reevaluation. 1. What are the communication patterns the nurse needs to be aware of in dealing with Mrs. Estrada? A. communication is typically direct, to the point, and impersonal. B. communication is typically absent of harsh criticism and confrontation. C. direct eye contact may be avoided. D. punctuality is valued.

B - Typical Cuban communication is smooth, interpersonal, and characterized by courtesy and respect. Harsh criticism and confrontation is considered rude and avoided. Direct eye contact is typically expected. Punctuality is not valued in formal or informal relationships unless a crisis exists.

(CHAPTER 6) 4. The nurse includes which information in the teaching plan about management of heart failure? (select all that apply) A. strict portion control at meals B. daily weight and record C. taking stairs instead of elevators D. avoiding artificial sweeteners E. salt restriction and salt substitutes

B and E - Monitoring weight is an important component of heart failure management -- Changes in weight may indicate an exacerbation of heart failure. Increased salt intake may precipitate an exacerbation of heart failure.

(CHAPTER 69) 2. During her first admission, which factor(s) place Mary at greatest risk of developing severe AWS? (select all that apply) A. diaphoresis B. age C. drinking history D. recent surgery E. pain

B, C, and D - Mary is age 64, has a history of excessive drinking, and was 2 days post-operative, all factors related to increased risk for severe AWS.

(CHAPTER 5) 2. Efforts to support family members include which of the following? (select all that apply) A. assuring them that the end is near and it is okay to go home. B. encouraging final private conversations with the patient. C. asking them to bring a few of the patient's favorite things to her room. D. telling them to encourage the patient to hold on for them. E. encouraging active discussions about favorite family memories.

B, C, and E - Sending the family home is inappropriate unless they desire to leave; encouraging the patient to hold on may prolong the dying process; encouraging private conversations, family discussions, and bringing favorite things from the home helps relieve anxiety.

(CHAPTER 6) 3. The nurse caring for Ms. Gomez, who is suffering from deconditioning from the recent hospitalization should add what to the plan of care? (select all that apply) A. maintain bedrest to prevent a fall B. start range-of-motion exercises C. limit dietary intake because of decreased activity D. referral for physical therapy E. education for safe ambulation and fall prevention

B, D, and E - Range of motion to maintain flexibility and physical therapy to help build an appropriate exercise schedule are essential. Safety and fall precautions are important to prevent injury.

(CHAPTER 68) Lauren Wiley is a 34-year-old diagnosed with obesity 15 years ago. She has tried various dietary and exercise programs along with pharmaceutical options. Lauren describes that her weight is interfering with her ability to walk and participate in social activities with her family. She is currently 5 ft 6 in. tall and weighs 256 pounds. She presents to her primary care provider to discuss a referral to a bariatric surgeon for weight loss. Ms. Wiley is referred to a bariatric surgeon by her primary care provider. Other than her obesity, Ms. Wiley also has mild hypertension and chronic joint pain. She is referred to an information session on bariatric surgery, and after this session, she decides to have laparoscopic RYGB surgery. The surgery is planned for the following week. Ms. Wiley undergoes gastric bypass surgery and has an uneventful postoperative course. On postoperative day two, her bowel sounds return and the NGT is removed, and she is allowed sips of clear liquids. She is discharged to home the following day with instructions to monitor her temperature every 4 hours and to contact the surgeon if she has an elevated temperature, nausea and vomiting, or increased pain. She is to return to the bariatric surgeon for postoperative follow-up in 7 to 10 days. 1. Ms. Wiley is 5 ft 6 in. tall and weighs 256 lb. The nurse calculates her BMI to be which value? A. 19 kg/m2 B. 34 kg/m2 C. 41 kg/m2 D. 49 kg/m2

C - BMI is calculated by dividing weight in kilograms by height in meters squared.

(CHAPTER 2) 3. Which statement is true about the follow-up appointments? A. the appointment can be cancelled if the patient is doing well. B. the appointment can be delayed if the patient is feeling well. C. it is important to follow up with the provider as planned. D. the appointment is unnecessary if the patient refuses to go.

C - It is extremely important that the patient goes to the follow up appointment. Research shows readmissions are increased if patients do not have early follow-up.

(CHAPTER 6) Ms. Gomez is an 87-year-old Hispanic woman with a history of hypertension and arthritis. She developed new-onset shortness of breath and was hospitalized. In the hospital, she was diagnosed as having congestive heart failure and was discharged to home with six new medications, oxygen therapy, and a sodium-restricted diet. Ms. Gomez is a widow and lives alone in her apartment. She has extended family who lives in the same apartment building. She speaks some English but mostly Spanish. She has been referred for home-care services and has been assigned a primary nurse. The goal is to have Ms. Gomez to remain safely at home. Before the first home visit, the primary nurse needs to arrange for a Spanish interpreter and a family member to be present so they can support and assist the patient during the assessment. An informed consent form for home-care services must also be obtained before the nurse can conduct an assessment. A complete physical and psychosocial assessment, a home safety assessment, and an assessment of the patient's medications are needed in order to develop nursing diagnoses and a plan of care to address Ms. Gomez's needs. In addition, the nurse will need to prioritize educating Ms. Gomez on home oxygen use and safety and assess her risk of falling as part of the home safety assessment. On the basis of the assessment findings, the nurse will demonstrate what other support services are needed. The nurse will communicate with the primary health provider to obtain medical orders for all anticipated services and to confirm medications. A plan of care based on the problems identified and nursing interventions to address them will then be implemented. The home-care nurse completes the first visit with the assistance of the Spanish interpreter and the patient's daughter, who lives in the same building. The findings include some shortness of breath with activity, no lower extremity edema, and normal breath sounds. Initial vital signs are: HR 95 bmp, BP 154/88 mmHG, RR 22 bpm, and temp of 98.8 F (37.1 C). The patient's weight is obtained with a home scale. The nurse now has baseline measurements against which to gauge future changes. For CHF patients, weight changes of 2 pounds or greater in 24 hours or 5 pounds in a week require immediate intervention to prevent exacerbation of heart failure or pulmonary edema and rehospitalization. Education on the safe use of home oxygen is conducted by the nurse, and both the patient and her daughter are able to give a correct return demonstration. The home-care nurse sees that Ms. Gomez has come home from the hospital with a decreased ability to ambulate steadily, and has suffered loss of strength and muscle tone. On the basis of all of these findings, the nurse identifies several problems that need to be addressed in the plan of care: decreased activity tolerance, deconditioning, and potential for exacerbation of CHF. Interventions to address these findings include directing the patient to maintain her daily weight and low-salt diet teaching. A referral for physical therapy is also indicated in order to develop a strength-building program and provide placement of assistive devices (cane, walker, wheelchair) as needed for provision of safe ambulation. A home health aide is also requested to assist Ms. Gomez with her personal care and her ADLs while she builds her strength and activity tolerance. The nurse encourages Ms. Gomex to express her concerns and fears related to increasing dependence on others and her changing role in the family. "I'm so tired and weak," she responds. "I'm a useless old lady now. I used to cook for everyone, and now I don't have the energy". It will be important for the nurse to reinforce progress as it develops and to help keep Ms. Gomez focused on her recovery. The nurse will utilize both family and outside social and community agencies to keep Ms. Gomez engaged and supported. The home-care nurse makes a follow-up visit to Ms. Gomez to evaluate the effectiveness of the plan of care and to continue assessing and monitoring the patient's physical and psychosocial status. Ms. Gomez has weighed herself and recorded the result with the assistance and guidance of her home-health aide and her daughter. The nurse provides education to all three about the patient's medications and supervises the daughter in filling the mediplanner. A physical therapist has visited and has initiated a home exercise program with Ms. Gomez. The nurse reviews with the patient her dietary intake for the previous day and reinforces the need for strict salt restriction in order to avoid fluid retention. To promote incentive for maintaining this, the nurse reminds Ms. Gomez that the goal is to prevent rehospitalization. Ms. Gomez continues to express feelings of frustration and hopelessness about her diagnosis and the aging process. The nurse requests a social work referral to provide a more in-depth psychosocial assessment and emotional support. During subsequent visits, the nurse assesses the patient for absence of symptoms, no weight gain, absence of edema, reduction of salt intake, and adherence to the medication schedule. Ms. Gomez is evaluated for returning strength and gradual increase in activity tolerance. The goal of aging at home is accomplished through collaboration with a team of people that includes the patient and her family, the provider, the home-health aide, the physical therapist, and the social worker. 1. Which statement by Ms. Gomez indicates that the teaching has been effective? A. "I'm not concerned with my weight as long as I take my pills" B. "Walking too much puts a strain on my heart" C. "I need to take my medications to stay out of the hospital" D. "As long as I take my meds, I can use salt"

C - Medication adherence is essential to maintaining health as is maintaining an appropriate weight, moderate exercise, and limiting salt intake.

(CHAPTER 2) Mr. Frank Garfield is a 67-year-old gentleman admitted after an acute cerebrovascular accident (CVA). The patient has a history of well-managed hypertension and atrial fibrillation, lives with his wife of 46 years, and was functionally independent prior to admission. Patient now presents with right-sided weakness and aphasia and has been placed on four new medications including an anticoagulant. He has been seen by various members of the interprofessional care team (ICT) including the unit-based nurse practitioner (NP). The patient and his wife are Spanish-speaking and are able to carry on simple conversations in English. The nurse recognizes the need to begin interprofessional collaboration (IC) to develop a safe discharge plan to return this patient to an optimal level of function and transition to the next level of care. Mr. Garfield is monitored as he slowly demonstrates signs of recovery. When the care manager meets with the patient's wife, she expresses concern that she is not sure she can care for him at home in his present condition but knows that he has expressed a desire to come home. She asks questions about what to do if his condition takes a turn for the worse because he has told her he "never wants to be on a machine". If she does take him home, she has no equipment in the home and does not know anything about his care or medications. During ICT rounds, the team discusses the need to engage therapists (physical, occupational, and speech), a pharmacist, and a nutritionist. Dual discharge-planning referrals are being made. A consult to the home-health coordinator (HCC) is made to develop a home-care plan. A second referral is made to the social worker for the long-term planning should a skilled nursing facility be considered to assist with rehabilitation and advance life planning decisions. Mr. Garfield's discharge plan is discussed in rounds. He continues to be hypertensive during the hospitalization so will need to go home with a prescription for an antihypertensive and close monitoring. Social work will work on insurance support for his prescriptions. An interpreter is available to help the nurse, pharmacist, and RD with patient teaching related to his hypertension, diet, and action/frequency/side effects of the medications. Teach-back is used to ensure that Mrs. Garfield is retaining the teaching provided. Mrs. Garfield decides to take the patient home. On day three of the hospitalization she assists the nurses in delivering his care On day four she provides care all on her own with supervision to gain confidence and skills prior to discharge. The HCC works to arrange equipment (hospital bed, bedside commode, and a wheelchair) and home-care services to including nursing, all three therapists, an SW, and a home health aide. A referral is made to a local skilled nursing facility just in case the plan fails at home. A follow-up provider appointment is made for the first week after discharge. 1. Which statement by Mr. Garfield indicates that teaching has been effective? A. "I don't need to get lab work when I feel well" B. "I'll take my pill when I don't feel good" C. "I have to take this pill even if I feel good" D. "My blood pressure isn't really that high; it won't cause a problem until it gets really high"

C - Patients need to follow the plan of care at all times such as getting lab work, treating high blood pressure, and taking their medications as prescribed in order to get the full benefit.

(CHAPTER 4) 4. Mr. Michaels is found to be mentally competent, but the family still does not want the gastrostomy tube placed. In the event the tube is not placed, this could be considered a violation of which ethical principle? A. veracity B. beneficence C. self-determination D. confidentiality

C - Self-determination related the patient's rights to make their own health-care decisions. Beneficence asks the question of who benefits from the action(s) taken by others. Veracity is the requirement to tell the truth, and requires that intentional misleading or deception of the patient to influence decisions is not done. Confidentiality requires that information is not shared beyond those who have a need to know.

(CHAPTER 3) 2. How would the nurse assist Mrs. Estrada in developing a plan for a 1,500-calorie diet? A. provide her with a menu from which she can select foods. B. provide a specific meal plan for three meals and two snacks. C. take inventory of Mrs. Estradas foods and preparation practices. D. ask her daughter to monitor her meals.

C - Taking an inventory of Mrs. Estrada's food and preparation practices gives her choices and helps ensure adherence to a prescribed diet. Providing a menu from which to select foods in not ideal. The food list might not have foods to which she has been accustomed. Providing a specific meal plan does not work on a long term basis. Whereas the daughter might help monitor Mrs. Estrada's diet, the daughter will not always be there and Mrs. Estrada needs to take responsibility of her own diet.

(CHAPTER 68) 4. The nurse is caring for Ms. Wiley in the presurgical suite. The patient asks, "Will you hold my hand? I am getting nervous. My mom told me this morning that I could die from this surgery". Which action by the nurse is best? A. patting the patient on the shoulder and covering her up B. asking her if she would like some alprazolam (Xanax) to calm her down C. holding her hand and listening to her concerns D. explaining that the percentage of people who die from bariatric surgery is small

C - The nurse should respond to the patient request by holding her hand and them employing active listening skills when a patient expresses a concern. Patting the pating on the shoulder rather than holding her hand as she requested would seem to diminish the patient's concern and seem patronizing. The nurse should not diminish the patient's concern by stating facts. Oral anxiety meds would be inappropriate in a patient preparing for gastric surgery.

(CHAPTER 5) Mrs. Kelso is a 79-year-old female with hypertension, past myocardial infarction, chronic obstructive pulmonary disease (COPD), congestive heart failure, and peptic ulcer disease. She has been living in her own home and was able to bathe and feed herself and perform light housework until she fell at home and suffered a subdural hematoma. The hematoma was surgically evaluated. Since the surgery, she has lost the ability to walk and had had ongoing changes in her mental status. She is not oriented to person, time, or place and does not interact with the caregivers. She sleeps most of the day, with only occasional periods of wakefulness. These changes in her mental status have resulted in the loss of full decisional capacity. Mrs. Kelso's daughter, Nancy, has become her surrogate decision maker with the input of other family members. They elect to continue fully aggressive care, as their primary goal is Mrs. Kelso's survival. She is eventually discharged to a rehabilitation facility in an attempt to improve her mobility. While in rehabilitation, Mrs. Kelso develops a urinary tract infection and sacral decubitus ulcers. Unable to participate in intensive physical therapy, she is discharged home bed-bound after 10 days with 24-hour caregivers. After 1 week at home, her home-care nurse notes that she is hypotensive and tachycardic. She is taken to the emergency department, where she is intubated and subsequently admitted to the intensive care unit with a diagnosis of sepsis. Cultures reveal an infected central line, pneumonia, and osteomyelitis related to decubitus ulcers. Her respiratory status eventually stabilizes, and she is extubated. She is often delirious, calling out and speaking in a confused manner. Although she is unable to tell the staff she is in pain, her discomfort is clear as she moans when turned and screams when her sacral dressings are changed. As Mrs. Kelso's condition continues to deteriorate despite aggressive care, and the need to discuss health-care goals, expectations, and hopes for recovery becomes clear. The health-care team believes that the patient is dying. As family members discuss their hopes and fears for the patient with the nurse, they become tearful. Using active listening, the nurse encourages the family to talk about the patient's past life, her relationships with her family, her love for gardening, and her involvement in church activities. The nurse asks the family if the patient ever expressed her wishes about end-of-life care. They state simply, "Our mother did not want to suffer". The health-care team discusses Mrs. Kelso's potential and actual suffering - physically, emotionally, and spiritually - and, with the family, develops a plan that includes palliative and hospice care. They develop a plan for the management of pain and respiratory distress. Morphine sulfate is ordered. The patient ceases moaning, her facial muscles relax, and her respiratory rate decreased to 18 per minute with no use of accessory muscles. The nurse documents her findings and incorporates symptom management into the care plan. Mrs. Kelso is transferred to inpatient hospice. She dies 2 days later. 1. The nurse caring for Mrs. Kelso understands her first priority should be to: A. call the chaplain B. ask family members for their understanding of the situation C. address the patient's pain D. call the ethics committee

C - The patient's comfort is paramount especially at the time of dying. Pain is the fifth vital sign. Addressing the patient's pain helps build trust with the family and will also help the family deal with their own grief as they witness their loved one not suffering. Answers A and B are appropriate after pain is addressed. Calling an ethics consult may be appropriate is there is a conflict about care.

(CHAPTER 3) 5. Mrs. Estrada wants to see a curandero. What response should the nurse give about seeing a curandero? A. explain that Western medicine is superior to traditional folk practitioners. B. inform her that curanderos practice witchcraft. C. ask permission for the nurse to contact the curandero. D. ask the curandero to contact the nurse.

C - Together the nurse and curandero can help assure that conflicting recommendations will not be provided. It is better for the nurse to contact the curandero rather than the curandero contacting the nurse because the curandero might not contact the nurse. Curanderos do not practice witchcraft and are well respected because they are known to the community. Cubans frequently seek their advice along with Western practitioners.

(CHAPTER 4) Joseph Michaels is a 45-year-old male who is attending a fourth of July picnic when he suddenly feels dizzy with loss of balance, trouble speaking, and a sudden headache. Family members assist Mr. Michaels in lying down, blame the symptoms on the hot day, and wonder is he has consumed too much alcohol. After a short while, he feels better and returns to the party. On the way home that evening, he again experiences the dizziness and headache, and his wife decides to take him to the local emergency department. Because he also demonstrates right-sided hemiplegia, global aphasia, and dysphagia, he undergoes a diagnostic evaluation and is diagnosed with a cerebrovascular accident, admitted to the intensive care unit, and started on anticoagulant therapy. Because of persistent swallowing problems, videofluoroscopy is conducted, and the findings indicate a severe swallowing disorder. Because of the danger of aspiration, the provider orders a nasogastric tube inserted for feeding purposes, with plans for possible gastrostomy tube placement if the dysphagia does not resolve. The family members tell the nurse they do not want any type of permanent feeding tube placed in the patient. The family has stated they do not want a gastrostomy tube placed. It is the responsibility of the nurse and the health-care team in general to provide enough information about the entire issue of the feeding tubes, both nasogastric and a skin-level device. Informed consent or dissent can be made only when the family has as much information about the benefits of each device. In the case of Mr. Michaels, part of the information needed is that his hemiplegia is improving, and he responds appropriately to commands and the surrounding environment. The decision is made to hold a conference to discuss whether a permanent tube should be placed. Additionally, a competency evaluation is scheduled for Mr. Michaels to determine his ability to make informed decisions based upon his improving level of consciousness. 1. To begin to assist this patient and family with decision making concerning a gastrostomy tube, which action should the nurse do first? A. report the family's decision to the prescriber. B. inform the family that the provider will make the best decision. C. offer to have another patient who has a gastrostomy tube to talk with the family. D. check the patient's chart for an advance directive or living will.

D - An advanced directive or living will is a legal document that provides the patient's decisions about life sustaining treatments and should be followed in this situation. It is not a decision to be made by the physician or health-care team.

(CHAPTER 3) 3. Mrs. Estrada expresses a desire to fo to the botanica to purchase some herbs. How would the nurse approach Mrs. Estrada's desire to use herbs instead of the prescribes oral hypoglycemia agent? A. tell her that taking herbs is very dangerous and should not be done. B. encourage her to go to the botanica because herbs do not affect blood glucose levels. C. give her a list of herbs that do not affect blood glucose levels. D. ask her to provide you with a list of herbs that she wishes to take.

D - Discouraging Mrs. Estrada from going to the botanica does not mean she will not go. Some herbs do not have an effect on blood glucose levels while others do. Knowing which herbs she wishes to use will help with medication adjustment.

(CHAPTER 68) 2. Ms. Wiley asks if she qualifies for bariatric surgery. What is the best response by the nurse? A. "No. You are healthy and therefore do not qualify for bariatric surgery" B. "Yes. You meet the BMI criteria, but I would not recommend bariatric surgery for someone so young. I know someone who died from it" C. "No. You do not meet the BMI criteria for bariatric surgery" D. "Yes. You meet the BMI, but there are several other factors that determine whether someone should have bariatric surgery"

D - Ms. Wiley does qualify for surgery based on BMI alone, but BMI is only a consideration for surgery. A and C provide inaccurate information. B is incorrect because the nurse should not impose personal beliefs on the patient.

(CHAPTER 68) 5. The nurse is caring for Ms. Wiley in the post-anesthesia recovery unit. The patient is 2 hours post gastric bypass surgery and has a nasogastric tube (NGT). The orders state the NGT should be hooked up to low continuous suction. There is scant blood-tinged drainage coming from the tube. What action should the nurse take? A. call the surgeon right away B. reposition the NGT C. discontinue the NGT D. document the findings

D - Patients are NPO and have a bowel prep before bariatric surgery. There should be no food in the stomach. A small amount of gastric acid tinged with blood is normal since the stomach and small intestinal lumen has been cut. The nurse should never remove or reposition a NGT in a bariatric surgery patient.