HESI Case Studies- Benign Prostatic Hyperplasia

Tests, along with urodynamic flow studies, indicate that Mr. Hamilton's prostate gland is enlarged significantly and treatment is recommended. Mr. Hamilton elects to try medical management of his symptoms. He receives prescriptions of oral finasteride (Proscar) and tamsulosin (Flomax). The nurse provides instructions about these medications. What information should be included when teaching Bob about Flomax?

"Change positions slowly, such as when standing up." Rationale: Tamsulosin is an alpha adrenergic blocking agent and is likely to cause orthostatic hypotension, especially when the client first starts the medication. This med is used to increase the flow of urine in BPH

It is determined that Mr. Hamilton experienced a febrile transfusion reaction. This type of reaction is caused by the body's sensitivity to components in the donor blood such as WBCs, platelets, or plasma proteins. In addition to stopping the transfusion, the nurse sends the blood bag, tubing, and a urinalysis to the lab, and administers and antipyretic medication until Mr. Hamilton is once again afebrile. The nurse is upset that Mr. Hamilton experienced a transfusion reaction and the nurse talks with the change nurse about the situation. The nurse states "I never thought I would get sued for malpractice. Do you think i will be sued because of this?" What is the best initial response by the charge nurse?

"Describe everything you did that is related to the transfusion?" Rationale: this is an assertive response by the charge nurse and offers both nurses an opportunity to review the situation to determine if malpractice occurred.

Mr. Hamilton tells the nurse that he is uncomfortable, because he constantly feels like he has to urinate. The nurse explains that this is the result of the oversize balloon putting pressure on the sphincter of the bladder. What instructions should the nurse relate to Mr. Hamilton?

"Do not try to void around the catheter." Rationale: the pt could damage the urinary sphincter if he tries to void around the catheter. Bearing down to try to urinate will create more pressure on the sphincter.

What instruction should the nurse provide Mr. Hamilton before starting the procedure?

"Empty your bladder completely." Rationale: the purpose of residual catheterization is to determine the amount of urine remaining in the bladder after voiding.

Mr. Hamilton's PSA level is 6mg/ml, a slightly elevated level (normal is <4 ng/ml). Bob appears distressed and asks, "Do I have prostate cancer? Is that why I'm having these symptoms?" How should the nurse respond? "I understand that this information is very complicated for a layperson to understand." "Perhaps this is a false positive result. I will call the lab to verify the results." "I realize that this report is causing you concern. PSA levels can be elevated with gland enlargement, as well as cancer, so more tests are needed." "I will notify your HCP of these results. He will discuss them with you."

"I realize that this report is causing you concern. PSA levels can be elevated with gland enlargement, as well as cancer, so more tests are needed." Rationale: elevated PSA levels are associated with prostate cancer. However, slight elevations may also occur in BPH. PSA levels may also be evaluated as the result of infection, or If the prostate gland is manipulated during a digital rectal exam.

Based on his continued lack of symptomatic improvement and high volumes noted during residual catheterization, Mr. Hamilton elects to have surgery. A transurethral resection of the prostate is performed (TURP). While Mr. Hamilton is in surgery, his wife brings his belongings to his assigned room on the surgical nursing unit. The nurse assigned to Mr. Hamilton's care greets her. The nurse recognizes that Mrs. Hamilton is of Asia descent and asks Mrs. Hamilton about her cultural background. Mrs. hamilton states that she is Korean and that she met and married Mr. Hamilton during the Korean War. The nurse asks Mrs. Hamilton if she has any questions or concerns . Mrs. Hamilton responds calmly that she will be happy when Mr. Hamilton returns from surgery, and Mrs. Hamilton turns her head and looks away. What is the best response by the nurse?

"I will be glad to answer any questions you may have." Rationale: this response gives Mrs. Hamilton the opportunity to choose any further interaction and respects the practices of her culture, which include avoidance of physical touch between persons who are not close.

Mr. Hamilton continues to take his medication for 9 months, but his symptoms do not improve significantly. He is scheduled for residual cathererization at the clinic. What catheter should the nurse select to perform the procedure?

- 12 French straight catheter Rationale: residual urine measurement does not require an indwelling cath, so a small, straight catheter is the best choice.

Mr. Hamilton asks if he will need to have any more yearly rectal exams. How should the nurse respond?

"You still need yearly rectal exams and PSA screenings." Rationale: since the prostate gland was partially removed during TURP, annual rectal exam and PSA screening should still be performed

Which assessment finding would indicate that Mr. Hamilton is experiencing urinary retention? -presence of a bruit auscultated over the renal artery -complaints of flank pain on gentle palpation -presence of frank hematuria on observation -dullness heard on percussion below umbilicus

-dullness heard on percussion below the umbilicus Rationale: a distended bladder will sound dull upon persussion

What analogy can the nurse use to describe how to contract the pelvic floor muscles?

Squeeze as if stopping the flow of urine.

During the night, Mr. Hamilton reports increased bladder discomfort. The nurse's observation of the urinary drainage catheter indicates minimal output for the last 2 hours. What action should the nurse take?

Stop the CBI, and irrigate the catheter. Rationale: the catheter is most likely obstructed by blood clots and should be manually irrigated with 30-50 mL of sterile, NS. The nurse should first check to make sure there are no kinks in the drainage tubing or other obvious signs of cathere obstruction.

Mr. Hamilton is scheduled to have emergency surgery as quickly as possible. His wife is with him, and she is very anxious and upset. While Mr. Hamilton is awaiting transport to the Operating Room (OR), which nursing staff should be assigned to his care?

A Rn who has worked on the unit for 3 years. Rationale: this is the best person to monitor an unstable pt

While the nurse is monitoring Mr. Hamilton closely, which additional responsibility is best to assign to the LPN?

Prepare a client with renal failure for a scheduled dialysis treatment. Rationale: this client is stable, and this task does not require the expertise of the RN

The nurse recognizes nonverbal behavior such as eye contact varies in different cultures. How can the nurse best interpret Mrs. Hamilton's minimal eye contact, in light of Mrs. Hamilton's cultural background?

A cultural practice based on recognition of someone's social status Rationale: in Korean culture, avoiding eye contact or engaging in minimal eye contact, is based on recognition of a person's status.

Early the next morning, the nurse notes that the catheter is draining a large volume of urine with bright red blood that seems thick. What actions should the nurse take? (select all that apply)

- Increase the flow rate of the CBI - Notify the HCP of the findings -Perform manual irrigation Rationale: the flow rate of the CBI should be increased, to decrease the risk for blood clot obstruction to the catheter Bright red bleeding with increased viscosity is an indication of arterial bleeding. The HCP should be notified immediately to determine the course of action necessary. in addition the flow rate of the CBI should be increased manual irrigation can be performed to help prevent blood clot obstruction and to resolve obstruction to the catheter.

Which additional manifestations would the nurse expect in client's with BPH? Select all that apply -hesitancy when starting urine stream -decrease in the size and force of urine stream -sharp pain when starting to void -unusual scrotal tenderness with swelling -frequent urination, including nocturia

- hesitancy when starting then urine stream -decrease in the size and force of urine stream -frequent urination, including nocturia Rationale: these are common signs of BPH

Mr. Hamilton tells the nurse that he has cut back on drinking fluids to reduce his symptoms. How should the nurse respond? "restrict fluid intake until test results are evaluated and the exact diagnosis is made." "increase the intake of diuretic-type fluids, such as coffee or tea, to increase urine flow." "add citrus juice to your daily fluid intake to boost immune defenses against infection." "decreasing fluid intake may increase your risk of developing a UTI."

-"Decreasing fluid intake may increase your risk for developing a UTI." Rationale: men with BPH often restrict fluid intake to reduce symptoms, but this should be discouraged because it increased risk for infection.

Mr. Hamilton is scheduled for a digital rectal exam, serum prostate-specific antigen (PSA) level, urinalysis, serum creatinine, and blood urea nitrogen (BUN). He states he has had the rectal exam and PSA levels done before the prostate screening. He asks why the other lab test (creatinine and BUN levels) are necessary. What explanation should the nurse provide? "if the kidney test results are normal, then your symptoms are probably not due to prostate enlargement." "if these kidney tests are elevated, dehydration, not prostate enlargement, may be the cause of your symptoms." "Prostate enlargement may be caused by altered or decreased urine production in the kidneys, which these tests will evaluate." "If your prostate gland is blocking the flow of urine, you may have some degree of kidney damage that can be detected with these test."

-"If your prostate gland is blocking the flow of urine, you may have some degree of kidney damage that can be detected with these tests." Rationale: as the flow of urine is blocked by the enlarged prostate gland, gradual dilation of the ureters and kidneys can occur, which will result in increased creatinine and BUN levels

What does Mr. Hamilton need to know about taking finasteride Proscar?

-Liver function studies (LFTs) need to be monitored frequently -most clients see significant change in BPH symptoms in 1 month -Medication should not be handled by women or children -Clients can experience breast tenderness and nipple discharge Rationale: Proscar can cause hepatic dysfunction, so LFTs results should be reviewed periodically. It may take 12 weeks to 6 months to achieve desired response Proscar can be absorbed through the skin and has been known to affect the genitals of developing male infants one of the AE of Proscar is breast enlargement and tenderness, which should be reported to the HCP

The nurses discuss the components needed to prove professional negligence or malpractice. They discuss "Breach of Duty." What statement best describes this term?

A nurse's actions do not meet established standards. Rationale: Breach of duty is the failure to perform according to established standards, such as those defined in state Nursing Practice Acts

Which nursing diagnosis has the highest priority when implementing care?

Altered cardiac output Rationale: hemorrhage has resulted in decreased cardiac output, resulting in hypovolemic shock, this is priority.

When the transfusion is half infused, the unlicensed assistive personnel (UAP) tells the nurse that Mr. Hamilton is very nervous and has a headache. Which action should the nurse implement first?

Assess Mr. Hamilton for additional symptoms. Rationale: pt is exhibiting signs of a possible transfusion reaction. The nurse should immediately assess pt for additional symptoms, such as fever or chills and then obtain vital signs

During administration of the aminocaproic acid (Amicar) infusion, the nurse monitors Mr. Hamilton for adverse effects of the medication. What assessment data would indicate the onset of thrombotic complication?

Chest pain and dyspnea Rationale: common manifestations of PE are chest pain and dyspnea

What action should the nurse take?

Document that the CBI is infusing correctly. Rationale: normal drainage is reddish pink, clearing to light pink within 24 hours postop. The drainage should be clear yellow by the 4th post op day.

The nurse administers oxygen per face mask, ensures that the IV is patent, and notifies the HCP that Mr. Hamilton is experiencing overt bleeding and manifestations of hypovolemic shock. Specimens for stat blood work and arterial blood gases are drawn. Which lab value would the nurse question?

Hemoglobin 15.0g/dL Rationale: Since pt is experiencing hypovolemic shock secondary to hemorrhage, both Hgb and Hct would decrease

The nurse assesses that Mr. Hamilton's skin is warm and flushed. Mr. Hamilton reports having generalized body aches and he starts experiencing chills. His BP is 114/68, his pulse is 92, his respirations are 18, and his temperature is 102.2. The nurse suspects that Mr. Hamilton is experiencing a febrile transfusion reaction. What action should the nurse take next after stopping the transfusion?

Infuse normal saline solution through separate IV tubing. Rationale: after stopping transfusion, the nurse should next infuse NS through a separate IV tubing to maintain patency. Pt may experience shock and may need additional fluids and medications

After surgery, Mr. Hamilton is admitted to the surgical nursing unit for overnight observation and postoperative care. Which postoperative intervention should the nurse perform first?

Observe the urinary drainage. Rationale: common postop complication that can be potentially life-threatening is bleeding which will be seen in the urinary drainage

The nurse assesses Mr. Hamilton and determines that he is dyspneic, lethargic, pale and cool. He is experiencing a large amount of bright red bleeding in his catheter. In what position should the nurse place Mr. Hamilton?

Supine with feet elevated at a 45 degree angle. Rationale: elevating the feet above the heart level promotes venous return, increasing the circulatory volume. The client's head may also be elevated to 30 degrees

The aminocaproic acid (Amicar) infusion successfully stops the bleeding without complications. Mr. Hamilton's hemoglobin and hematocrit drop as the result of the bleeding, and the HCP prescribes the administration of 1 unit of packed red blood cells. Which action should the nurse implement to reduce the risk for a hemolytic transfusion reaction?

Verify the blood type and Rh factor with another nurse. Rationale: acute hemolytic reactions are the result of the infusion of incompatible blood products. This risk is reduced if two nurses verify and compare the label on the blood with the clients identification band and the blood bank form. start transfusion slowly and observe client for the first 15 to 30 mins of transfusion