HESI Case Study - Pernicious Anemia

Mr. Baker starts vomiting. The nurse looks in his medication administration record and notices that he has a prescription for treating nausea and vomiting. He has also not had any of it since he was admitted to the unit. The healthcare provider has prescribed ondansetron (Zofran) 8 mg iv push every 8 hours as needed. How many milliliters (mL) of ondansetron (Zofran) should the nurse should draw into a syringe in preparation for administration? (enter numerical value only. If rounding is necessary, round to the whole number.)

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Which action is most important for the nurse to perform before calling the healthcare provider (HCP) to report the lab values? A. Initiate telemetry. B. Complete an SBAR form. C. Give PO potassium chloride. D. Notify the unit manager.

A Although telemetry does require a healthcare provider's order, most hospitals have a standing order/protocol in place for situations such as this one. Telemetry placement is essential to protect the client from potential decompensation due to cardiac dysrhythmias which could occur due to hypokalemia.

The healthcare provider (HCP) has also prescribed a single dose of intravenous (IV) magnesium sulfate 2 mg in 100 mL of 5% dextrose in water over one hour to be given now. The nurse is preparing to give the prescribed intravenous (IV) magnesium. Which laboratory values should the nurse monitor cautiously before starting the medication? A. Blood urea nitrogen (BUN) and serum creatinine levels. B. White blood cell (WBC) and red blood cell counts (RBC). C. Activated partial thromboplastin time (aPTT). D. Hemoglobin (Hb), hematocrit (Hct), and platelet count.

A Magnesium is eliminated by the kidneys; therefore, renal function should be monitored. The BUN and creatinine levels offer a convenient indirect evaluation of kidney function.

The nurse asks the client how he is feeling. He reports that he does not have time for this hospitalization. The nurse notes that he seems annoyed. He coughs as he tries to sit up. He turns on the television, focuses on a news station, and ignores the nurse. Which type of assessment should the nurse perform on the client? A. A focused assessment. B. A comprehensive assessment. C. An emergency assessment. D. A psychosocial assessment.

A This assessment is for evaluating the status of specific previously identified problems and any symptoms of new problems developing.

The nurse receives shift report and proceeds to the client's room, bringing equipment to measure his vital signs. Which vital sign should concern the nurse the most? A. Blood pressure is 142/80 mmHg. B. Respiration rate of 24 breaths/minute. C. Heart rate of 98 beats/minute. D. Pulse oxygenation of 94%.

A This elevated blood pressure could indicate an underlying issue that should be addressed.

The nurse notices that the client has no central line and only has one peripheral intravenous catheter in the left forearm. Which intervention is the best way to give the ordered potassium? A. Consult with a pharmacist about giving it slowly over two hours. B. Administer the intravenous potassium as it was ordered. C. Call the healthcare provider and request a new order. D. Inject lidocaine into the intravenous bag and give as prescribed.

A This option is the easiest way to prevent vein irritation while administering the ordered medication. Pharmacists are the best colleagues to consult for situations like this one. Most of the time, the pharmacist can adjust the medication; however, if this is not the case, the pharmacist can also assist with communicating with the healthcare provider (HCP).

The nurse has received new orders by electronic medical record (EMR) in response to the recent laboratory results. One of the orders is for intravenous potassium chloride 20 mEq/100 mL over one hour. Which drug implications are important for the nurse to consider before giving it? (Select all that apply. One, some, or all options may be correct.) A. The intravenous site should be monitored closely for infiltration. B. Giving the infusion too rapidly can cause fatal hyperkalemia. C. It should be injected directly and slowly by intravenous push. D. The intravenous infusion is best given through a central line. E. The intravenous potassium can be given by gravity infusion. F. Administering the intravenous medication can burn a peripheral vein.

A, B, D, F This is a very important nursing action as infiltration can lead to painful and damaging extravasation around the intravenous catheter site. This is a true statement. This is the preferred intravenous route; however, a slower flow rate can be used if this is not possible. This is an important nursing consideration and can be rectified by slowing the rate and/or reducing the potassium concentration in the intravenous medication bag.

Morning laboratory results have begun appearing in the client's electronic medical record (EMR). Which electrolyte deficiency would make the nurse suspect that this client may be suffering from chronic alcohol use? A. Potassium. B. Magnesium. C. Phosphate. D. Sodium.

B A magnesium deficit is consistent with the client's assessment findings, and it is commonly associated with chronic alcohol use.

The client says that he is feeling better and it is now time to give the scheduled medications. Because of the new medical diagnosis of pernicious anemia, the healthcare provider (HCP) has prescribed cyanocobalamin (vitamin B12) 100 mcg/day subcutaneously (SQ) for seven days with a follow up clinical visit for laboratory work on the seventh day. Before giving the medication, what should the nurse do first? A. Sign off the medication in the electronic medical record (EMR). B. Teach the client about the medication being given. C. Locate the ventrogluteal muscle of the left hip. D. Ask if the client has been NPO for the last 8 hours.

B Teaching the client about their medication enhances medication safety and contributes to discharge teaching.

The following day, after all consultants have either met with the client or the attending healthcare provider (HCP), the nurse prepares for a follow up discussion about treatment options. The psychologist reports that the client has newly diagnosed alcohol misuse, and he has probably had it for quite some time. He has reported that he usually enjoys about three quarts of whiskey each week. The client agrees to the nurse's request to sit with him for a while to discuss his treatment plan. His usual disengaged and surly affect has changed significantly. Today he is pleasant and very glad to see the nurse. What question should the nurse ask the client first? A. Are you able to tell me about your treatment plan? B. Do you have any thoughts of harming yourself? C. Have you been drinking any alcohol at all today? D. How do you feel about your new diagnosis of alcohol misuse?

B The sudden affect change for the better after discussing an array of distressing problems (recent loss of business partner, illness, poor health, social isolation) should alert the nurse that it is possible that the client may have decided to attempt suicide. Asking the question never will give the client the idea to consider a suicide attempt, and it is a safety responsibility to assess the client for this possibility.

The nurse finishes documenting the client interview and notices that new laboratory results have been posted in the electronic medical record (EMR). The nurse notes that the serum magnesium level is 1.22 mg/dL (0.50 mmol/L), and the normal range is 1.58 to 2.55 mg/dL (0.65 to 1.05 mmol/L). Which other result will need intervention? A. Chloride of 99 mEq/L (99 mmol/L). B. Potassium of 2.9 mEq/L (2.9 mmol/L). C. Glucose of 105 mg/dL (5.83 mmol/L). D. Sodium of 137 mEq/L (137 mmol/L).

B This is a low serum potassium level; normal range is 3.5 to 5 mEq/L (3.5 to 5 mmol/L).

The healthcare provider (HCP) writes discharge orders for the client. The nurse provides discharge instructions that includes prescriptions to be filled by his chosen pharmacy, the date and time of his follow up appointment, and other self-care information on a printed document for him to take home. Which intervention is most important for the nurse to perform after giving the client his discharge information? A. Advise him to attend Alcoholics Anonymous (AA). B. Document the teaching in his medical record. C. Escort him to his car to ensure his safety. D. Provide a list of foods high in vitamin B12.

B This is an important action for the nurse to take after providing discharge teaching.

The client informs the nurse that he can quit drinking any time he chooses and that he is not interested in psychotherapy or attending any Alcoholics Anonymous (AA) meetings. How should the nurse respond to these statements? A. Ask the client if he has a better solution than going to psychotherapy. B. Acknowledge that it's great that the client is taking better care of himself. C. State that you would be glad if the client would agreed to attend an AA meeting. D. Have the client state why won't he at least attend an AA meeting.

B This response reflects on what he is doing for himself, respects the client's decision, and keeps the conversation open for further interaction with him. It is also a good transition to discussing his medications with him in preparation for discharge to home. He has agreed to grief support meetings, which is also an open door.

In collaboration with the nurse, the attending healthcare provider (HCP) has consulted several specialists for a conference to plan the client's care. The nurse is also preparing to initiate a follow up discussion about treatment options with the client after the meeting. Which consultants will be most helpful during this meeting? (Select all that apply. One, some, or all options may be correct.) A. Occupational therapy. B. Hematologist. C. Psychologist/Psychiatrist. D. Gastroenterologist. E. Internist. F. Speech therapy.

B, C, D, E He is exhibiting the signs of pernicious anemia, such as weight loss, nausea, vomiting, shortness of breath, pallor, weakness, inflamed tongue, tremors, and severe fatigue. He has grief issues, as well as possible chronic alcohol use and social isolation. He has a history of chronic gastritis and his symptoms are nausea, vomiting, and weight loss, and he has developed pernicious anemia. He has been diagnosed as having hypomagnesemia and hypokalemia.

The nurse performs a focused assessment. Which systems should the nurse evaluate? (Select all that apply. One, some, or all options may be correct.) Select all that apply. A. Neurological system. B. Cardiovascular system. C. Respiratory system. D. Integumentary system. E. Gastrointestinal system.

B, C, E The client has hypertension and an elevated heart rate. The client has a cough. The client has a history of having gastric ulcers and he currently has nausea and vomiting symptoms.

The client thanks the nurse for the concern and states that he does not have a desire to attempt suicide. He states that since he has had some rest, good food, and medical treatment, he is feeling much better. He tells her what he knows about his treatment plan: He will start attending grief support meetings and taking better care of himself in general, but he will not be going to psychotherapy or attending any Alcoholics Anonymous meetings. The client has not mentioned what he will do about his chronic alcohol use while describing his treatment plan. Which term would the nurse use to summarize where he is in his alcohol misuse treatment plan? A. Depression. B. Bargaining. C. Denial. D. Acceptance.

C Denial is the first stage of grief, and it is a common reaction to a new and unpleasant discovery affecting a person's life. This response reflects that he does not acknowledge that he has a alcohol misuse problem.

The nurse finds that the client has a weak, irregular, and rapid pulse and his tongue is inflamed. The nurse decides to perform a neurological assessment because of mild tremoring. His unexpected neurological findings include hyperactive deep tendon reflexes and mild burning and prickling sensations on his feet and hands. He also appears to startle easily, and he has lost about 15% of his weight compared to his last visit, which was four months ago. During the assessment, the nurse suspects that the client may have pernicious anemia. Which pathophysiological process promotes this condition? A. Presence of Reed-Sternberg cells. B. Diminished total iron-binding capacity. C. Destruction of gastric parietal cells. D. Inadequate intake of dietary folate.

C Pernicious anemia is often associated with chronic gastritis. This is because destruction of gastric parietal cells due to inflammation and cellular hypoxia causes gradual gastric atrophy and a reduction of available intrinsic factor, which is a transporter molecule that is required to promote the bioavailability of vitamin B12.

The client is 45-years-old. Which life style choice is surprising given his psychosocial developmental stage based on Erikson? A. His sexual preferences. B. He prefers to live in a city where there is a lot of action. C. He enjoys staying out all night at his favorite local bar. D. He works ten to twelve hours every day in the office.

C Regularly staying out all night is the behavior of someone younger who is seeking intimacy which, according to Erikson, is a psychosocial developmental stage for early adulthood. Middle adulthood is staged as a time of generativity versus stagnation.

Before giving cyanocobalamin, the nurse teaches the client about his medication. The client interrupts the teaching session and asks, "What happens if I just do not take the shots?" What is the best way for the nurse to respond? A. Are you not going to comply with this prescription? B. It sounds like you do not want to take these shots. C. You will gradually get very ill and die in 1 to 3 years. D. Let me talk to the healthcare provider and get you the tablets.

C This statement is truthful. The length of time depends on many factors, such as the amount of functional intrinsic factor his stomach is still able to produce and how much vitamin B12 is provided by his diet.

The nurse is reviewing the client's electronic medical record (EMR) and is discussing with the healthcare provider (HCP) the possible need for an interprofessional conference with the client due to the increasing complexity of his medical problems. The nurse uses a problem-solving approach with the client to facilitate interprofessional communication and assists the healthcare provider (HCP) with obtaining appropriate consults to better inform the team of identified issues for promoting the changes needed for this client. To begin this process, the nurse creates a list of known problems. Which problems should the nurse include in this evaluation? (Select all that apply. One, some, or all options may be correct.) A. Social isolation. B. Chronic alcohol use. C. Chronic gastritis. D. Pernicious anemia. E. Electrolyte imbalances. F. Grief and loss.

C, D, E, F This diagnosis is measurable, and the signs and symptoms have been apparent for quite some time. He has nausea, vomiting, and weight loss, and he has developed pernicious anemia due to fewer functioning gastric parietal cells. The primary care physician and dietician could both be consulted. This diagnosis is measurable and the signs and symptoms apparent, such as nausea, vomiting, shortness of breath, pallor, weakness, inflamed tongue, tremors, and severe fatigue. The primary care physician and dietician could both be consulted. Physical therapy could assist with anemia related musculoskeletal issues. This diagnosis is measurable and the signs and symptoms are apparent. He has been diagnosed as having hypomagnesemia and hypokalemia during this hospitalization. His primary HCP could be consulted. The dietician could also be consulted for education on food/dietary regimes to enhance electrolyte imbalances. This diagnosis is measurable and the signs and symptoms apparent. He lost his business partner in a recent accident. A social worker, pastoral care, psychotherapist could be consulted.

Which sign or diagnostic result should the nurse expect to observe in a client due to hypokalemia? A. An arm tremor while taking the client's blood pressure. B. Hyperactive deep tendon reflexes. C. Elevated serum glucose level. D. A dampened or flattened T-wave on an electrocardiogram (ECG).

D A dampened or flattened T-wave on an electrocardiogram (ECG) is an expected finding due to hypokalemia. This is also the reason that the client should be placed on telemetry until the hypokalemia is resolved.

The nurse notes that the client has had many personal losses in his life, and he recently lost his legal partner in an accident. His electronic medical record (EMR) has no one listed as a person to contact in case of emergencies. Which question is the best way for the nurse to begin assessing the client's support systems and available resources? A. "Can you tell me more about what happened to your professional partner?" B. "Which neighborhood bar do you regularly go to after work in the evenings?" C. "I'm sorry for your loss. Was your legal partner also your domestic partner?" D. "Who would you like to have listed as your emergency contact person?"

D Initiating the conversation using a focused question for information about electronic record data omissions is a less threatening way to begin to ask the question, "To whom can you go to for support at home or at work?"

Several hours have passed and all medications have been given. The healthcare provider (HCP) is thinking about discharging client. The client's latest laboratory test results have arrived in his electronic medical record (EMR), and the nurse has performed another focused assessment. Which findings satisfy the nurse that the potassium electrolyte replacement medication has been effective? A. The client's mood and affect have improved significantly. B. The client's nausea and vomiting have resolved, and appetite has returned. C. Lack of tremoring when inflating the blood pressure cuff on the left arm. D. A 12-lead electrocardiography strip confirms a normal sinus rhythm and potassium level is 4.6 mEq/L (4.6 mmol/L).

D This result shows that the intravenous potassium has resolved the hypokalemia and the T-wave has returned from flatted to normal size. Normal potassium levels range from 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L.)

The nurse assesses the client's lifestyle choices to explore what resources he has for health promotion. Which lifestyle choice could concern the nurse about a client with possible chronic alcohol use? A. Sexual preferences. B. He works ten to twelve hours every day in the office. C. He prefers to live in a city where there is a lot of action. D. He enjoys staying out all night at his favorite local bar.

D While the bar may provide social stimulation, it also provides access to alcohol.

Introduction

The client is a 45-year-old male who was admitted to the medical-surgical unit 6 hours ago from the Emergency Department (ED) due to nausea, vomiting, shortness of breath, pallor, weakness, and severe fatigue. He also has had a medical history of chronic gastric ulcers.