HESI CASE STUDY - Pernicious Anemia Mr. Baker

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.) Ondansetron hydrochloride Oral solution 4 mg / 5 ml 50 ml

10 4 mg / 5 ml = 8 mg / X ==> X= 40/4 ==> X=10

The nurse is preparing to give the cyanocobalamin as prescribed. This label comes from the medication packaging that the pharmacy delivered for Mr. Baker. What should the nurse do next? NASOCOBAL Nasal spray 500 mcg/spray 1.3ml (4 sprays) One bottle 4 doses

Hold the medication and call to inform the pharmacist. Cyanocobalamin is the right medication, but the wrong route has been provided.

The nurse notes that Mr. Baker has had many personal losses in his life, and he recently lost his legal partner in an accident. His electronic health record has no one listed as a person to contact in case of emergencies. Which comment is the best way for the nurse to begin assessing Mr. Baker's support systems and available resources?

Who would you like to have listed as your emergency contact person? Initiating the conversation using 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?"

The pharmacy delivers another vial of cyanocobalamin. The healthcare provider has prescribed subcutaneous vitamin B12 (cyanocobalamin) 100 mcg daily for seven days. How many milliliters (mL) of cyanocobalamin should the nurse draw into a syringe in preparation for administration? (Enter numerical value only. If rounding is required, round to the tenth.) Cyanocobalamin Injection 1,000 mcg/ml 1 ml vial For IM or SubQ use

0.1 1000 mcg / 1 ml = 100 mcg / X ==> X= 100/1000 ==> X= 0.1

Several hours have passed and all medications have been given. The healthcare provider is thinking about discharging Mr. Baker. Mr. Baker's latest laboratory test results have arrived in his electronic health record, and the nurse has performed another focused assessment. Which finding satisfies the nurse that the potassium electrolyte replacement medication has been effective?

A 12-lead electrocardiography strip confirms a normal sinus rhythm. This result shows that the intravenous potassium has resolved the hypokalemia and the T-wave has returned from flatted to normal size.

Which sign or diagnostic result should the nurse expect to observe in a client due to hypokalemia?

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

The nurse asks Mr. Baker how he is feeling today. 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 Mr. Baker?

A focused assessment. 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 Mr. Baker's room, bringing the vital sign measurement equipment. Which vital sign should concern the nurse the most?

Blood pressure is 142/80 mmHg. This elevated blood pressure indicates an underlying issue that must be addressed.

The healthcare provider has also prescribed a single dose of intravenous magnesium sulfate 2 mg in 100 mL of 5% Dextrose in Water (D5W) over one hour to be given now. The nurse is preparing to give the prescribed intravenous magnesium to Mr. Baker. Which laboratory values should the nurse monitor cautiously before starting the medication?

Blood urea nitrogen and serum creatinine levels. 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 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 this prescription?

Consult with a pharmacist about giving slowly over two hours. This option is the easiest way to prevent vein irritation while administering the prescribed medication. Pharmacists are the best colleagues to consult for situations like this one. Most of the time, the pharmacist can adjust the prescription; however, if this is not the case, the pharmacist can also assist with communicating with the healthcare provider.

Mr. Baker thanks the nurse for the concern and states that he does not have a desire to commit 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. Mr. Baker has not mentioned what he will do about his drinking habit while describing his treatment plan. Which term would the nurse use to summarize where he is in his alcohol treatment plan?

Denial. 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 drinking problem.

The nurse finds that Mr. Baker 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 included 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 as 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?

Destruction of gastric parietal cells. 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 following day, after all consultants have either met with the client or the attending healthcare provider, the nurse prepares for a follow up discussion about treatments options. The psychologist reports that Mr. Baker has newly diagnosed alcoholism, and he has probably had it for quite some time. He has reported that he usually enjoys about three quarts of whiskey each week. Mr. Baker 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 Mr. Baker first?

Do you have any thoughts of harming yourself? 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 commit 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 healthcare provider writes discharge prescriptions for Mr. Baker. The nurse provides discharge instructions that include 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 Mr. Baker his discharge information?

Document the teaching in his health record. This is an important action for the nurse to take after providing discharge teaching.

In collaboration with the nurse, the attending healthcare provider has consulted several specialists for a conference to plan Mr. Baker's care. The nurse is also preparing to initiate a follow up discussion about treatment options with Mr. Baker after the meeting. Which consultants will be most helpful during this meeting? (Select all that apply.)

Gastroenterologist. Psychologist/Psychiatrist. Internist Hematologist.

Mr. Baker is 45-years-old. Which life style choice is surprising given his psychosocial developmental stage?

He enjoys staying out all night at his favorite local bar. Regularly staying out all night is the behavior of someone younger who is seeking intimacy.

The nurse assesses Mr. Baker's lifestyle choices to explore what resources he has for health promotion. Which lifestyle choice may concern the nurse about a client with possible chronic alcoholism?

He enjoys staying out all night at his favorite local bar. While the bar may provide social stimulation, it also provides access to alcohol.

The nurse is preparing to give the cyanocobalamin as prescribed. This label comes from the medication packaging that the pharmacy delivered for Mr. Baker. What should the nurse do next?

Hold the medication and call to inform the pharmacist. Cyanocobalamin is the right medication, but the wrong route has been provided.

Which action is most important for the nurse to perform before calling the healthcare provider to report the lab values?

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

Mr. Baker 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 meetings. How should the nurse respond to these statements?

It's great that you are taking better care of yourself. 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.

Morning laboratory results have begun appearing in Mr. Baker's electronic health record. Which electrolyte deficiency would make the nurse suspect that this client may be suffering from chronic alcoholism?

Magnesium. A magnesium deficit is consistent with the client's assessment findings, and it is commonly associated with chronic alcoholism.

The nurse is reviewing Mr. Baker's electronic health record and is discussing with the healthcare provider the possible need for an inter-professional conference with the client due to the increasing complexity of his medical problems. The nurse uses a problem-solving approach to client inter-professional consultation and assists the healthcare provider with obtaining consultants to better inform the process 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.)

Pernicious anemia. Chronic gastritis Electrolyte imbalances. Grief and loss.

The nurse finished documenting the client interview and notices that new laboratory results have been posted in the electronic health record. The nurse notes that the serum magnesium level is 1.0 mEq/L (0.50 mmol/L), and the normal range is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Which other result will need intervention?

Potassium of 2.9 mEq/L (mmol/L). This is a low serum potassium level; normal range is 3.5 to 5 mEq/L (mmol/L).

The nurse performs a focused assessment. Which systems should the nurse evaluate? (Select all that apply.)

Respiratory system. Cardiovascular system.

Mr. Baker 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 has prescribed vitamin B12 (cyanocobalamin) 100 mcg/day subcutaneously 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?

Teach the client about the medication being given. Teaching the client about their medication enhances medication safety and contributes to discharge teaching.

The nurse has received new prescriptions by electronic health record in response to the recent laboratory results. One of the prescriptions 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.)

The intravenous infusion is best given through a central line. The intravenous site should be monitored closely for infiltration. Administering the intravenous medication can burn a peripheral vein. Giving the infusion too rapidly can cause fatal hyperkalemia.

Mr. Baker then says to the nurse, "I have heard of people using the nasal spray. Why can't I be prescribed the nasal spray?" Which response should the nurse give the client?

You may be able to after you have achieved remission from pernicious anemia. Mr. Baker has chronic gastritis which has caused a reduction in the total functional surface area of this stomach lining. Without this lining, he cannot produce enough intrinsic factor to transport the cyanocobalamin to the small intestine for absorption and use. Some healthcare providers prescribe intranasal cobalamin, but only after achieving remission from pernicious anemia by a series of intramuscular or subcutaneous injections.

Before giving cyanocobalamin, the nurse teaches Mr. Baker about his medication. Mr. Baker 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?

You will gradually get very ill and die in 1 to 3 years. 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.