Nursing
NP
NP Clinical Scenarios
Health Assessment
Respiratory
100
You are caring for a resident at the end of life. The resident tells you that they are grateful for having considered and decided upon some end of life decisions and the appointments of those who they wish to make decisions for them when they are no longer able to do so. During this discussion with the client and the resident’s wife, the resident states that “my wife and I are legally married so I am so glad that she can automatically make all healthcare decisions on my behalf without a legal durable power of attorney when I am no longer able to do so myself” and the wife responds to this statement with, “that is not completely true. I can only make decisions for you and on your behalf when these decisions are not already documented on your advance directive.” How should you, as the nurse, respond to and address this conversation between the husband and wife and the end of life?
A: You should respond to the couple by stating that only unanticipated treatments and procedures that are not included in the advance directive can be made by the legally appointed durable power of attorney for healthcare decisions.
B: You should be aware of the fact that the wife of the resident has a knowledge deficit relating to advance directives and durable powers of attorney for healthcare decisions and plan an educational activity to meet this learning need.
C: You should be aware of the fact that the resident has a knowledge deficit relating to advance directives and durable powers of attorney for healthcare decisions and plan an educational activity to meet this learning need.
D: You should reinforce the wife’s belief that legally married spouses automatically serve for the other spouse’s durable power of attorney for health care decisions and that others than the spouse cannot be legally appointed while people are married
A: You should respond to the couple by stating that only unanticipated treatments and procedures that are not included in the advance directive can be made by the legally appointed durable power of attorney for healthcare decisions.
100
A 65-year-old female is starting hemodialysis. The NP asks the patient if she has a copy of her advance directives. The patient replies, “No, I’m not ready to die.” Which of these responses by the NP would be best?
a. “We will be obligated to do everything possible unless you tell us otherwise.”
b. “Do you want your family to make these decisions for you?”
c. “This is an opportunity for us to discuss your wishes and goals.”
d. “Are you aware the mortality rate for patients with kidney disease is 20% annually?”
Answer: c
Rationale: Talking with patients about advanced directives is part of meaningful discussion, informed consent, and self-determination regarding treatment options and preferences.
100
The NP is conducting a neurological examination for a 79-year-old male patient who experienced an unobserved fall and possibly hit his head against the wall. The NP finds that the patient has a positive Romberg’s sign. The NP understands that a positive sign indicates:
a. Dizziness.
b. Vertigo.
c. Normal aging change.
d. Loss of equilibrium.
Answer: d
Rationale: A positive Romberg’s sign test three sensory systems that provide input to the cerebellum to maintain truncal stability. These are vision, proprioception, and vestibular sense.
100
What is the name for this?
What is a Snellen Chart?
100
This is a collapse of the alveoli that prevents normal exchange of oxygen and carbon dioxide.
What is Atelectasis?
200
You are caring for a group of elderly members, many of whom are affected with multiple chronic disorders and are also, at times, affected with some acute disorders that require medical and nursing attention. As you are caring for these residents some will need a new medication regimen for an acute disorder. You should consider that fact that the elderly population is at risk for more side effects, adverse drug reactions, and toxicity and over dosages of medications because the elderly have a (n):
A: Increased creatinine clearance.
B: Impaired immune system.
C: Decreased hepatic metabolism.
D: Increased bodily fat
C: Decreased hepatic metabolism
The elderly population is at risk for more side effects, adverse drug reactions, and toxicity and over dosages of medications because the elderly have a decrease in terms of their hepatic metabolism secondary to the hepatic functioning changes of the elderly secondary to a decreased hepatic blood flow and functioning.
The elderly have decreased rather than increased creatinine clearance; the immune system is also decreased in terms of its functioning, however, this change impacts on the elderly’s ability to resist infection rather than impacting a medication’s side effects, adverse drug reactions, toxicity and over dosages; and, lastly, a decrease in terms of bodily fat, rather than an increase in terms of bodily fat impacts on medications. The distribution of drugs is impaired by decreases in the amount of body water, body fat and serum albumin; drug absorption is decreased with the aged patient’s increases in gastric acid pH and decreases in the surface area of the small intestine which absorbs medications and food nutrients.
200
A 67-year-old female patient who the NP is seeing for first time. She was placed in a facility recently by Adult Protective services. Previously, she was living in a van on the street. She has not had any healthcare in years, but she believes that she is healthy. What are the recommended vaccines that she would need to be up to date?
a. Tdap and Measles only.
b. Tdap, measles, and flu vaccines only.
c. Tdap, pneumococcal, and flu vaccines only.
d. Tdap, pneumococcal, vaccines, shingles, and flu only
Answer: d
Rationale: Tdap, pneumococcal, vaccines, shingles, and flu vaccines are what is recommended by the CDC for this age group.
200
A 75-year-old woman has the following DEXA T-scores: femoral neck (right) -2.5, femoral neck (left) -1.9, and lumbar spine -1.3. The following pharmacological agents are useful in treating her condition EXCEPT:
a. calcitonin (Miacalcin).
b. denosumab (Prolia).
c. alendronate (Fosamax).
d. risendronate (Actonel).
Answer: a
Rationale: Not a first-line drug for osteoporosis. Avoid in patient in whom hip fracture is the primary concern.
200
This is a picture of what?
What is a Barrel Chest?
200
This is what is associated with hypoxia.
What is dyspnea?
300
Your resident has a tube feeding. Which of the following commonly occurring complications of tube feedings can you prevent with the preventive measure that is coupled with it?
A: Constipation: The provision of a high fiber diet
B: Urinary pH changes: Encouraging ample oral fluid intake
C: Aspiration: Maintaining the resident in at least a 30 degree angle
D: Aspiration: Maintaining the resident in at least a 90 degree angle
C:
Aspiration can be prevented by maintaining the resident in at least a 30 degree angle; a 90 degree angle is not only not necessary, this angle places a client at greater risk for the development of a pressure ulcer.
Diarrhea, rather than constipation is a complication of tube feedings; and urinary pH changes are not a commonly occurring complication of tube feedings.
Some of the other complications and preventive measures are:
- Diarrhea: Maintaining a slow rate of infusion whenever possible, changing the ordered rate and formula when necessary
- Abdominal pain: Maintaining a slow rate of infusion whenever possible
- Dehydration: Monitor the resident for any signs and symptoms of dehydration, measure intake and output and notify the doctor of any abnormalities
- Nausea and Vomiting: Slowing the rate down, changing the formula and antiemetic medications to stop the vomiting and to prevent any aspiration
- Tube Dislodgment: Secure and monitor the tube
300
A 79-year-old male patient is recovering from surgery, as he had a colectomy for colon cancer. He still has an abdominal wound that is healing slowly, and he is having a lot of pain with dressing changes, to the point where he is yelling out in pain during the entire treatment. The SNF nurse asks the NP for pre-medication order to ease his suffering. The NP orders:
a. Acetaminophen.
b. Tramadol.
c. Ibuprofen.
d. Hydrocodone
Answer: d
Rationale: Acetaminophen is only recommended for the treatment of mild pain. Tramadol and ibuprofen are to be used with caution in elders. Hydrocodone is a good choice for moderate pain.
300
The NP assesses a 79-year-old bedbound resident at a long-term care facility who has a right trochanter pressure injury. The dimensions of the pressure injury are 2.5 cm x2.0 cm x 0.3 cm. The wound bed is pink and is draining a large amount of serous exudate. What type of dressing should be ordered? a. Transparent film.
b. Calcium alginate.
c. Hydrocolloid.
d. Hydrogel.
Answer: c
Rationale: Calcium alginate is an absorptive product for moderate to large amount of exudate. The other products are indicated for low to moderate draining pressure injury.
300
When assessing the abdomen this is how long you auscultate if nothing is heard.
What is 5 minutes.
300
This is the transient imbalance between oxygen supply and demand.
What is Angina Pectoris?
400
One of the primary purposes of a formal medication reconciliation is to:
A: Prevent polypharmacy
B: Conserve financial resources
C: Prevent interactions
D: Prevent allergies
C
The medication reconciliation process to insure that the nurse is aware of all medications that the resident is taking, some of which may have been ordered by a physician/NP other than the resident’s primary care doctor. The complete and current list of medications is then reviewed by the nurse and possible interactions are identified and addressed with the resident.
400
A 72-year-old woman, with a history of depression, has been stable with Citalopram 20 mg daily for several years. She had a recent stroke. She was initially participating with physical therapy, but now, the physical therapist is concerned about the patient’s lack of progress. She tells the NP that she is not interested in therapy, because it is “not going to help me anyway”. The NP notices that she is spending more time in bed and is eating much less than she used too. Which of the following should the NP consider as a next step?
a. Increase Citalopram to 40 mg.
b. Add Paroxetine.
c. Add Mirtazapine.
d. Stop the citalopram for a ‘wash out’ period.
Answer: c
Rationale: The max dose for Citalopram is 20 mg in the geriatric population. Paroxetine is on the Beer’s list due to its anticholinergic properties. A wash out would not be a good option, as the patient was doing well on the medication before her stroke. Therefore, adding mirtazapine is the best choice.
400
An 80-year-old male with multiple comorbid conditions presents with vague symptoms of fatigue. His RBC indices indicate that he is normocytic, normochromic, and reticulocytopenic. Treatment for this type of anemia should include:
a. Remedy the underlying condition.
b. Iron Sulfate (FeSO4) supplement replacement.
c. Weekly epoetin alfa (Epogen) injections
d. Folic acid supplement replacement.
Answer: a
Rationale: Based on the presentation the NP should recognize this individual has anemia of chronic disease. Focusing treatment on the underlying conditions lead to resolution of anemia of chronic disease.
400
This is described as...
What is purulent drainage?
400
You are caring for a resident in which you expect an acute exacerbation of COPD. What findings do you expect to find in this resident?
Select all that apply
A. Decreased 02 saturation on mild exertion.
B. Widened diaphragm on chest radiology.
C. Increased vital capacity during pulmonary function testing.
D. Hypocapnia
E. Hyperinflated lung on chest x-ray.
A.: Correct /true , due to narrowed airway clearance and inability to exchange oxygen for c02 your client will exhibit low 02 saturation levels. Clients with COPD usually sat around 85%.
B: Incorrect/ false in a client with COPD the diaphragm will appear flat on x-ray due to accumulated scar tissue and decreased lung compliance from long standing hyperinflation damage.
C: incorrect / False: We will see a decreased vital capacity due to damage to the lung tissue and diaphragm
D: Incorrect,/false, we know that a client suffering from COPD will have hypercapnia . This occurs because of narrowing airways and inability to exchange 02 and co2. You may also see ABG results showing respiratory acidosis because of this.
E: Correct/true , this is a clinical manifestation of COPD. Hyperinflated lungs can be caused by blockages in the air passages or by air sacs that are less elastic, which interferes with the expulsion of air from the lung
500
Which lipid level would you address because it is not normal and it is also a significant change in the resident?
A: Triglycerides: 75 mg/dL
B: Total cholesterol: 6.5 mmol/L
C: High-density lipoprotein (HDL): 60 mg/dL
D: Low-density lipoprotein (LDL): 955 mg/dL
B
You would report a total cholesterol level of 6.5 mmol/L because this value exceeds the high normal for total cholesterol which is 5.5 mmol/L and the normal range is from 3 to 5.5 mmol/L.
The other lipid levels are normal as follows:
- Triglycerides: 50-150 mg/dL
- High-density lipoprotein (HDL): 40-80 mg/dL
- Low-density lipoprotein (LDL): 85-125 mg/dL
500
Which organ is responsible for drug metabolism and must be considered when prescribing medication for an older adult?
What is the Liver?
500
A 69-year-old female has multiple sclerosis and resides in a long-term care facility. She is only able to get up to her wheelchair with the use of a Hoyer lift, since she can no longer stand on her own. She has a catheter due to urine retention, which caused her many urinary tract infections despite proper catheter care by the nursing assistants. When she gets an infection, she has pain, which makes her very anxious. The next step the NP would consider in reducing her UTI risk is to:
a. Use a larger gauge catheter to encourage better draining of urine.
b. Start an antibiotic for UTI prophylaxis.
c. Have the catheter changed weekly instead of monthly.
d. Use a silver tipped catheter.
Answer: b
Rationale: The larger catheter will not help reduce UTI. The more frequently you change a catheter, the more you risk UTI. Silver catheters do not reduce the risk of UTI.
500
(Full Name) What is in the nurse's hand?
What is a Jackson-Pratt Drainage Device?
500
Adventitious Breath Sounds:
Describe rales, rhonchi and wheezes and when heard (inspiration/expiration/both)
Rales: fine, medium or coarse. Fine: high-pitched/popping sound. Heard during inspiration.
Wheezes: high-pitched musical sound. Heard on inspiration and expiration. Continuous.
Rhonchi: low-pitched sound. Continuous and prolonged. Sometimes hard to distinguish b/t crackles and rhonchi. Have resident cough, if it disappears it is usually rhonchi.