Critical Thinking Cases In Nursing Answer Key

She asks why their pills are different shapes and colors. • Start by explaining that many different drugs are used to treat HTN. • ABGs: Used to monitor respiratory status/oxygenation. • Assess and monitor emotional responses and coping mechanisms to pain. You can see flutter waves, with varying numbers between the QRS intervals. responded to heparin therapy, was started on warfarin therapy, and is being discharged to home with home care follow-up. He is likely to have another DVT develop from sitting on the plane (not to mention sitting at the wedding and reception). He has a history of heart failure, high cholesterol, hypertension (HTN), sleep apnea, and depression. has just been admitted to the hospital for surgical repair of a 6.2-cm abdominal aortic aneurysm (AAA) that is now causing him constant pain.

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It is critical to provide the primary care provider with accurate, timely assessment data after the change from IV to oral diuretic therapy. The most essential aspect of teaching hospitalized patients is to focus on realistic key points. Laboratory Testing (Fasting) Total cholesterol 240 mg/d L HDL 35 mg/d L LDL 112 mg/d L Triglycerides 178 mg/d L 1 Cardiovascular 13 CHAPTER 1 CARDIOVASCULAR DISORDERS CASE STUDY 3 5. ” Which is considered the “good cholesterol,” and why? The HDL (high density lipoprotein) cholesterol is considered the “good” cholesterol because it has protective properties. • Praise his wife for being supportive in helping both of them live a healthier lifestyle. There are many excellent books and magazines available on tasty, low-fat healthy eating. If necessary, teach positive relaxation techniques that he can use when he is on the road. I grew up in a really dysfunctional family where there was a lot of violence. I find myself suddenly awakening at night just to see if he’s breathing.” How are you going to respond? Acknowledge that heart disease in a loved one can be a very frightening thing. stop any activity and sit or lie down because you want to decrease the workload on his heart and decrease his body’s need for oxygen. The pain is related to posture and is not made worse with exertion or relieved with rest. In addition, cigarette smoking can cause transient arterial constriction. P.’s primary care provider has seen him and wants you to schedule the patient for an ankle-brachial index (ABI) test to determine the presence of arterial blood flow obstruction. • Do not use heating pads and hot water bottles—the skin has poor circulation and is subject to injury. Vital Signs Temperature 97.9° F (36.6° C) Blood pressure 142/83 mm Hg Heart rate 105 beats/min Respiratory rate 18 breaths/min Difficulty: Intermediate Setting: Outpatient clinic Index Words: coronary artery disease (CAD), heart failure (HF), laboratory values, medications, therapeutic nutrition Case Study 6 Coronary Artery Disease and Heart Failure 1 Cardiovascular 26 PART 1 MEDICALSURGICAL CASES 2. Also ask about microwave meals, lunch meats, canned foods, fast foods or restaurant foods, and Do you wake up during the night with shortness of breath? Does your heart race at times or flutter, skip beats, pause, or thump? stopped smoking 10 years ago.) Occupational history: This question is critical with respect to smoking history. Digoxin levels must be monitored carefully because digoxin toxicity can lead to serious complications. • Avoid hot or cold environments; both increase cardiac demand. • Are they accompanied by other signs and symptoms (S/S), such as nausea/vomiting (N/V), diaphoresis, shortness of breath, dizziness, weakness, palpitations, or anxiety? Answers: A, C, F SL NTG should be placed under the tongue and allowed to dissolve naturally and not swallowed until the drug is entirely dissolved.

What will determine whether the oral dose will be adequate to consider her for discharge? Using the mnemonic MAWDS, what key management concepts should be taught to prevent relapse and another admission? For those at risk for CAD, the fasting total cholesterol should be below 200 mg/d L, the HDL should be above 40 mg/d L, the LDL should be less than 100 mg/d L, and the triglycerides should be less than 150 mg/d L for men. asks you, “So, how is my ‘good cholesterol’ doing today? Those who smoke a pack of cigarettes per day have more than twice the risk of MI than nonsmokers. What is the highest priority problem that you need to address with B. You may help him change his outlook because this is something he thinks is important. • The American Heart Association, the American Lung Association, and the American Cancer Society all have excellent literature and programs on smoking cessation. Focus your teaching around a low-fat diet to decrease obesity and hyperlipidemia risks. For example, drinking a lot of beer is not a healthy technique. T.’s wife takes you aside and tells you, “I’m so worried for B. I’m so worried I’ll lose him that I have nightmares about his heart stopping. is still uncomfortable, and he has an unopened bottle of sublingual nitroglycerin (SL NTG) tablets. After 5 minutes, which is the appropriate action to take? • Another possible source of hip pain could be pseudoclaudication—this pain is due to neurospinal canal compression. Tobacco use: Smoking is associated with increased serum concentrations of cholesterol. The changes put the individual at increased risk for atherosclerosis and heart disease. 1 Cardiovascular 19 CHAPTER 1 CARDIOVASCULAR DISORDERS CASE STUDY 4 CASE STUDY PROGRESS S. • Avoid exposing the right leg to temperatures less than 70Åã F (21.1Åã C) to prevent vasoconstriction and subsequent reduction of arterial blood flow. 1 Cardiovascular 24 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Laboratory Testing Chemistry Sodium 142 m Eq/L Chloride 95 m Eq/L Potassium 3.9 m Eq/L Creatinine 0.8 mg/d L Glucose 82 mg/d L BUN 19 mg/d L CBC WBC 5400/mm 3 Hgb 13 g/d L Hct 41% Platelets 229,000/mm 3 Initial Assessment Complains of increased fatigue and shortness of breath, especially with activity, and “waking up gasping for breath” at night, for the past 2 days. Do you sometimes feel like you can’t get your breath (shortness of breath)? Many foods like chips, peanuts, pizza, pickles, canned soups, turkey dressing, and ham (fill in local or ethnic salt-rich favorites) contain salt. Try to relate salt intake to symptoms that started 2 days ago. Cardiac rhythm: Are you having any strange feelings in your chest (palpitations)? If potassium levels get low, the hypokalemia can make the patient more susceptible to digoxin toxicity. He says he would rather eat a banana every day than take one of those pills. • Tell him there are other ways the physician can order the potassium, such as in a liquid form or a powder form that is dissolved in liquid. • Minimize stress to reduce sympathetic nervous system response to increased workload of the heart. He is currently taking amlodipine (Norvasc), metoprolol (Lopressor), atorvastatin (Lipitor), and aspirin 81 mg/day. What other information are you going to ask about his episodes of chest pain?

All of these will have different shapes and colors, so the same drug may have several different appearances. There are no abnormal physical findings; however, he hasn’t had a bowel movement for 3 days. Atherosclerosis injures vessel walls, causing weakness. HTN: The elevated blood pressure (BP) puts a continuous strain on weakened arterial walls.

This can be confusing, so patients should always double check with their pharmacist to ensure there has been no mistake if their medication looks different. His electrolytes, blood chemistries, and clotting studies are within normal range, except his hematocrit is 30.1%, and hemoglobin is 9 g/d L. Advanced age: HTN and atherosclerosis are more common in the elderly. awaits his surgery, it is important that you monitor him carefully for decreased tissue perfusion. Identify five things you would assess for, and state your rationale for each.

She was diagnosed with hypertension (HTN) 2 months ago and was given a prescription for a thiazide diuretic but stopped taking it 2 weeks ago because “it made me dizzy and I kept getting up during the night to empty my bladder.” During today’s clinic visit, she expresses fear because her mother died of a cerebrovascular accident (CVA, stroke) at her age, and M. P.’s blood pressure falls under which classification? Diuretics, such as HCTZ, should be taken in the morning so that the diuretic effects do not disturb sleep. would be considered either at optimal weight or even slightly underweight. In people who are saltsensitive, the most effective technique has been the “no salt shaker” approach (i.e., don’t add salt to food when cooking, and don’t have a salt shaker on the table). The rapid yet irregular ventricular rate decreases ventricular filling and reduces cardiac output. What is the purpose of the warfarin (Coumadin) in K. During atrial fibrillation, blood pooling in the quivering atria might lead to thrombus formation, which might lead to embolic events, such as pulmonary embolus or cerebrovascular accident (CVA). INR results are independent of the reagents or methods used, thus providing more standard monitoring. For deep-vein thrombosis prophylaxis, the preferred INR levels would be 1.5 to 2.0. also has a mechanical valve, the preferred INR would be as high as 3.0 to 4.0. When you get the results, his INR is critical at 7.2. In lay terms, his blood is “too thin.” Difficulty: Beginning Setting: Outpatient anticoagulation clinic Index Words: atrial fibrillation, bleeding complications, warfarin, patient education, PT/INR monitoring, vitamin K, enoxaparin, safety precautions Case Study 5 Atrial Fibrillation and Oral Anticoagulation 1 Cardiovascular 22 PART 1 MEDICALSURGICAL CASES CASE STUDY PROGRESS The health care provider does a brief focused history and physical examination, orders additional lab tests, and determines that there are no signs of bleeding other than the nosebleed, which has stopped. If yes, take a complete drug history: type, quantity, frequency, route. Pneumothorax: The patient would experience sudden, sharp chest pain and shortness of breath. • Call the physician if you have S/S of infection, such as fever or excessive redness, swelling, unusual pain, or drainage at the incision site.

reduce cardiac stimulation by catecholamines Answer: D Beta blockers reduce or prevent stimulation of the heart by circulating catecholamines. 1 Cardiovascular 5 CHAPTER 1 CARDIOVASCULAR DISORDERS CASE STUDY 2 􀁘 Scenario M. is a 65-year-old African-American woman who comes to your clinic for a follow-up visit. She states, “I’ve never smoked and I don’t drink, but I am so afraid of this high blood pressure.” You review the data on her past clinic visits. According to the most recent Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, M. She could be taking the HCTZ in the late afternoon or evening, instead of in the morning. What nonpharmacologic lifestyle alteration measures might help someone like M. A good way to identify salt-sensitive people is to monitor BP on and off salt; if the BP decreases when salt is withheld, then the person is saltsensitive, and limiting salt might bring about a modest decline in BP. With atrial fibrillation, the atria beat in a disorganized manner, with a rate of 350 to 600 times per minute—as if they are “quivering.” The result is no atrial contractions with an irregular ventricular response; in fact, the ventricles often beat with a rapid rate in response to the increased number of atrial impulses. You ask him to come into the office to check his coagulation levels. INR stands for “international normalized ratio,” a mathematical calculation. His health care provider will want to examine him to determine whether he has other complications associated with excessive anticoagulation. recently went to the local urgent care center for a sinus infection and had received a prescription for the antibiotic co-trimoxazole (sulfamethoxazole-trimethoprim) (Septra). ” Stress: Find out what stressors he has in his life and what he does when he is feeling stressed. Drug use: Has he taken any street drugs or abused prescription medication in the past? Which actions are correct when taking SL NTG for chest pain? 1 Cardiovascular 33 CHAPTER 1 CARDIOVASCULAR DISORDERS CASE STUDY 7 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Hematoma at the incision site: You would see evidence of increased ecchymosis, swelling, and tenderness at the incision site. What information will you give him before he leaves the hospital?

Studies have shown that long-term exercise compliance is better in individuals engaging in lower to moderate-intensity exercise rather than higher intensity exercise. She tells you she is feeling fine and does not have any side effects from her new medication. • Just as medications are prescribed (type, dose, time, route), exercise for cardiac patients should be prescribed in these terms: • Type of exercise (what kind) • Intensity of exercise (how hard)—usually as pulse or perceived exertion • Frequency of exercise (how often)—usually beginning 3 days per week • Duration of exercise (how long)—usually measured in minutes or distance • What is the safest level of activity for G. He has had two previous episodes of DVT and was diagnosed with rheumatoid arthritis 3 years ago. J.’s health history and admitting diagnosis, what are the most important assessments you will make during your physical examination and assessment? I will call to ask the physician to switch medications.” b. You might need to hold gentle pressure on the injection site to reduce bleeding, but do not massage the site because this will also increase bruising. True or False: Enoxaparin dosage is directed by monitoring activated partial thromboplastin time (a PTT) levels. • Do not cross legs; crossing legs can decrease circulation.

Although some patients may need to start walking as little as 3 to 5 minutes daily and increase by 1 to 2 minutes 1 Cardiovascular 7 CHAPTER 1 CARDIOVASCULAR DISORDERS CASE STUDY 2 per week, the eventual goal is to walk briskly, without discomfort or shortness of breath, for 30 minutes five or six times per week. with education about the common side effects of benazepril, which can include which conditions? Her BP, checked twice a week at the senior center, ranges from 132 to 136/78 to 82 mm Hg. When someone is taking HCTZ and an ACE inhibitor, such as benazepril, what laboratory tests would you expect to be monitored? Compare these readings with the national standards and the goal you both agreed on. List at least three important ways you might help her maintain her success. that these readings are improving and that you’ll pass them on to the physician. comes in for a routine follow-up visit 3 months later. P., and what problems could develop at what intensity? Two months ago he began experiencing shortness of breath on exertion and noticed swelling of his right lower leg that became progressively worse until it extended up to his groin. Warfarin (Coumadin), an oral anticoagulant, would be given because of his history of multiple DVT and atrial flutter/fibrillation. Cardiovascular: Obtain baseline vital signs (VS); assess heart sounds; compare perfusion of the extremities. “It would take the Coumadin pills several days to be effective.” c. • Do not massage right leg; massage could dislodge a thrombus.

Patients taking beta blockers cannot use normal exercise heart rate recommendations and require special guidelines. is instructed to return to the clinic in 1 week to have her blood work checked. had been complaining of dizziness, which may be caused by orthostatic hypotension. It is especially important to monitor potassium levels; the HCTZ can cause decreased levels, but ACE inhibitors, such as benazepril, can cause potassium levels to increase. • Remind her of the therapeutic goal you worked on with her. Therapeutic goals are individualized; however, these BP readings are improved and at the “prehypertensive” levels, according to the national guidelines. • Review her progress over the past months with her. • Remind her of the necessity of adhering to her treatment plan (because she is doing so well) and to keep checking her BP and taking her medications as directed. She continues to do well on her daily BP drug regimen, with average BP readings of 130/78 mm Hg. 1 Cardiovascular 35 CHAPTER 1 CARDIOVASCULAR DISORDERS CASE STUDY 8 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. His wife brought him to the hospital when he complained of increasingly severe pain in his leg. Venous compromise of affected leg: Assess warmth, redness, pain, edema, Homans’ sign, distal pulses, capillary refill, and baseline calf and thigh girth. Lungs: Assess breath sounds; assess for dyspnea and chest pain. Pulmonary embolism CASE STUDY PROGRESS Your assessment of L. reveals bibasilar crackles with moist cough; normal heart sounds; blood pressure (BP) 138/88 mm Hg; pulse 104 beats/min; 3 pitting edema of right lower extremity; mild erythema of right foot and calf; and severe right calf pain. Why can’t I just get a Coumadin pill to thin my blood? “Your physician prefers the injections over the pills.” d. • Keep right leg elevated without pressure under the knee to promote circulation.

Here are some rules of thumb for exercise: (1) If you are stiff, sore, or exhausted as a result of the exercise, you have done something wrong or have done too much; and (2) if you are out of breath during exercise, you are doing too much. • Interventions, like stress management, might work with some individuals, but studies on the efficacy of these interventions are less convincing. P.’s HCTZ dosage to 12.5 mg PO daily and adds a prescription for benazepril (Lotensin) 5 mg daily. She is also instructed to monitor her BP at least twice a week and return for a medication management appointment in 1 month with her list of BP readings. Why did the internist decrease the dose of the HCTZ? The elderly might be more sensitive to hypotensive effects, and dosage adjustments can help reduce this problem. Both drugs can cause decreased sodium and creatinine levels. She participates in a senior citizens group-walking program at the local mall. When a Doppler study indicated a probable thrombus of the external iliac vein extending distally to the lower leg, he was admitted for bed rest and to initiate heparin therapy. Mental status: Assess for confusion, restlessness, and lethargy. He is awake, alert, and oriented but a little restless. He denies chest pain but does have shortness of breath with exertion. List at least eight assessment findings you should monitor closely for in the development of the complication identified in Question 5. “The enoxaparin will work to dissolve the blood clot in your leg.” Answer: B Enoxaparin takes 3 to 5 hours to reach maximum antithrombotic activity; warfarin (Coumadin) takes 12 to 24 hours for onset and peaks in 1. It takes several days for warfarin to reach an effective anticoagulation level. • Avoid sudden muscle movement of affected limb, which could dislodge a thrombus. What pertinent laboratory values or test results would you expect the physician to order and you to monitor? • Platelet count: Enoxaparin might decrease the platelet count. • CXR: For evaluation of pulmonary and cardiac systems.


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