Answer the two following questions:
1. What ethical principles did Eunice Rivers attempt to uphold in her long nursing practice? Explain your answer.
2. Ought she to share part of the blame for the reprehensible research project that involved withholding both accurate information and appropriate treatment? Explain your answer.
Revisiting Nurse Rivers
Lisa Kearns
Keywords: narrative medicine, Tuskegee study, race
INTRODUCTION:
The Tuskegee syphilis study’s most enduring figure is also one of its most intriguing. Nurse Eunice Rivers was instrumental to the study for both procuring its members and then keeping them involved in it. Straddling as she did the professional medical world and the world of the study’s subjects, she was the ideal link between the disparate spheres.1 Over the years, historians who have studied Rivers have found her to be a complex character: a black woman who betrayed her race even as she sought to improve the black subjects’ well-being; a nurse who betrayed her profession by dooming those she was charged with caring for. Through modern eyes, she becomes more victim than betrayer: a victim of her gender, powerless to speak up in a man’s world, or a victim of race herself, powerless in a world controlled by whites.2 Susan Smith, in “Neither Victim Nor Villain,” analyzes the Tuskegee study from the perspective of Rivers as a black professional, in the historical context of her gender and race. 3 Another, equally compelling way to look at Rivers is also within a historical context, again as a medical professional, but this time as one attempting to practice that profession during an economically devastated and racially repressive period of American history. The poverty and unemployment prevalent in the rural South of the 1920s and 1930s is the background against which Rivers ought to be evaluated. And although social conditions don’t provide excuses for her involvement in the infamous study, they do offer a context in which to try to make sense of her participation.
ANALYSIS:
The economic boom before the crash of 1929 didn’t skip the South, but its effects there were much different than in other parts of the country. By 1920, for the first time in United States history, most Americans lived in cities, and by 1940 an additional 6 million farmers had left the fields for urban areas, among them cotton growers from the South.4 For rural America, then, the boom before the bust meant a population drain, and in the decade following World War I the South was the most rural region in the country.5 As wartime demand for agricultural products (chiefly cotton) gave way after Armistice Day to material surpluses and over farmed land, farmers migrated in droves to urban centers. Left behind were those who either could not or would not follow suit. Yet, David Kennedy notes, “the urbanization of early twentieth-century America can be exaggerated. More than one in five working Americans still toiled on the land in the 1920s.” At the same time, “a stubborn agricultural depression, the product of war and technological change, badly exacerbated the problems of the countryside.” In 1930 four-fifths of all blacks remained in the South.6 President Herbert Hoover decided to address the social problems of the time by gathering the brightest minds in the country (a month before the market crash of October 29, 1929) and asking them to amass nationwide data and analysis that would be, according to Hoover, “the basis for the formulation of large national policies looking to the next phase in the nation’s development.”7 The report was delivered in 1933: the exhaustive Recent Social Trends, which provided data on everything from the nation’s mineral resources to the impact of new technology on work and home life. Writes Kennedy, “From its turgid prose and endless tables emerged a vivid portrait of a people in the throes of sweeping social, economic, and political change, even before they were engulfed by the still more wrenching changes of the Depression era.”8 That turgid prose also revealed a stark conclusion: If residents of the rural South were suffering during that era, black residents were suffering significantly worse. Earlier immigration restrictions (via literacy tests, for example) culminated in a 1921 quota law, followed by an even more stringent one in 1924 and then another in 1929. 9 The resulting reduced immigrant workforce created employment opportunities for blacks in towns and cities, furthering emptying rural farms of tenant farmers and sharecroppers; a devastating boll weevil infestation in Southeast cotton fields spurred even more relocation as crops failed.10 Those who stayed in the countryside lived in deplorable conditions. By as late as 1940, homes for both black and white tenant farmers were valued at around $250. Few houses had running water; fewer still had flush toilets.11 Black farmers also faced a credit system that was particularly unfavorable to them. The usurious interest rates they were charged (15 percent to 35 percent) drastically ate into already meager profits. “This crop mortgage system is weak to begin with and its abuses make it even more burdensome,” Recent Social Trends reported. “With these handicaps the returns from farming are small… After this small product has been divided between tenant, the landlord and the furnisher of credit, the shares are inadequate to support a good standard of living.”12 It was in this bleak social and economic landscape that Rivers found herself when she was starting her career. And if she hadn’t noticed it from the confines of the nursing program at the Tuskegee Institute, she witnessed it firsthand after her 1922 graduation in her first job, with the Movable School. Tuskegee Institute founder Booker T. Washington wanted to teach agricultural techniques to black farmers in the last decade of the 19th century. That idea led to the establishment of an agricultural extension department at Tuskegee and ultimately the Movable School,13 so named because it brought a learning center to people (first by a mule-drawn wagon and later via truck). The original “Farmers’ College on Wheels” initially educated farmers on new technology and methods to help improve crop and livestock yields. In 1918, federal funding allowed the hiring of home economics instructors, who taught women canning, cooking, and cleaning,14 and later public health professionals came on board to teach basic hygiene and sanitation skills.15 In 1923, Rivers joined the school as a public health nurse. In addition to basic hygiene, she taught women and midwives safe birthing methods, childcare, and how to tend to the sick, and provided men information on “social hygiene,” euphemism for sexually transmitted diseases.16 The Movable School ventured to the farthest rural corners of Alabama, including Macon County, the pool from which prospective subjects for the Tuskegee study would be drawn. For Rivers, the Movable School was more than just an opportunity to advance the Tuskegee Institute’s philosophy of service to the indigent; it was a job at a time when jobs were scarce, and it was a good one at that. Landing it was an achievement in itself. Black nurses had fewer employment opportunities than white nurses did, and Southern black nurses lucky enough to find work were paid lower salaries for performing the same duties as their white counterparts. In Alabama, for example, white nurses were paid $110 a month by the board of health, while black nurses received $65.17 The openly racist attitudes of even those in the profession compounded the economic inequalities. Darlene Clark Hine writes of Margaret Bruesche, a white nursing teacher in Fairfield, Alabama, who felt that “the negro woman has no place as a graduate nurse.” They weren’t smart or well educated, “they are not conscientious, and their sense of responsibility is very weak.” (At least Bruesche was ostensibly assessing professional skills. A white nursing superintendent at Atlanta’s Grady Hospital at the time felt black nurses hadn’t “any morals… They are such liars…and will cut up each other’s clothes for spite.”)18 Rivers remained with the Movable School for nine years, until the Depression forced financial cutbacks that led to the elimination of her position, leaving her to choose between unemployment and a night nursing supervisor position at the John A. Andrew Memorial Hospital at the Tuskegee Institute. She chose the latter. She hated working the night shift, and less than a year later, as she was preparing to migrate north herself, she heard about a job with the United States Public Health Service, working on a study of the effects of untreated syphilis on black men.19 It was an assistant’s position, paying a then- attractive $1,800 a year.20 River’s years with the Movable School in and around Macon County, and her concurrent work for the Bureau of Vital Statistics for the Alabama Health Department compiling birth and death records in the same area, were on-the-job preparation for the Tuskegee position. Her experience and performance were impressive enough that Dr. Eugene Dibble, medical director of the Tuskegee Institute and head of the Andrew Hospital, recommended Rivers, who had been one of the institute’s star nursing school pupils, for the opening. She was hired for the study in 1932 to monitor the participation of its black subjects.21 With 21st-century eyes it might be difficult to see how a black woman would be willing to participate in something called “The Tuskegee Study of Untreated Syphilis in the Negro Male.” But in light of the prevailing economic conditions in the rural South early in the previous century, it is not so hard to discern reasons why. Syphilis was rampant and posed a serious health threat, and treatments available then were harsh. (“I saw so many reactions with these medications,” Rivers said in an interview). 22 The natural progression of the disease was to be studied in hopes of determining better treatments.23 By taking the job with the U.S. Public Health Service, Rivers would be working to help the people she knew to be in desperate need of medical attention. Also, in the beginning decades of the 1900s, it was presumed that the course of the disease progressed differently through blacks than it did through whites—the Tuskegee study would complement the Oslo study of untreated syphilis in whites.24 “This is the way I saw it: that they were studying the Negro just like they were studying the white man, see, making a comparison,” Rivers said later.25 Yet given the scarcity of good jobs for black women, in the rural South in particular, a perhaps more compelling reason for Rivers to join the study is simply that it offered employment—and a chance to get off the odious night shift. (“I was so glad to go off night duty that I would have done anything,” Rivers said). 26 That the position was one in the career for which Rivers had trained was a bonus. Nursing positions were not easy to come by, and the Depression was forcing state public health departments to cut funds.27 The unemployment rate for the country was approaching 25 percent.28 Rivers was an ideal candidate for the job. She had been an exemplary student at Tuskegee. She’d done administrative work for the Bureau of Vital Statistics, and nursing school had trained her to examine patients. The Movable School had taught her public outreach and the interpersonal skills of a public health nurse; her personality and tact were remarkable.29 In fact, Dr. Dibble cited her effectiveness as a public health worker when he suggested her for the Tuskegee position.30 The relationships she established with the people in Macon County from her Movable School days would be the key to her success in the Tuskegee job. Other syphilis studies were being conducted at the time, and a lack of patient compliance with treatment protocols was an ongoing, pervasive challenge. A Birmingham, Alabama, doctor who had worked with public health syphilis programs noted that failing to keep up with treatment until cure was an issue for both blacks and whites, and that developing a way to keep patients compliant would be essential to any program’s success.31 As it turned out, Rivers excelled at making sure that patients enrolled in the study stuck with it. The study was originally designed to last six to eight months, but of course it went on far longer, and by the time the decision was made to leave the termination date open-ended, Rivers was a firmly entrenched Tuskegee team member. After all, notes Susan Smith, “Rivers considered her participation in the study merely a continuation of her previous public health work.”32 Over the course of the study she had become more than just an assistant; she was, if not in title, the de facto chief liaison between the doctors and the subjects. Dr. Raymond Vonderlehr, director of the Public Health Service’s venereal disease division and the head of the study from its inception till 1943, acknowledged River’s skills in ensuring the ongoing compliance of the subjects.33 If River’s complicity in withholding treatment in the original study can be understood within the economic and employment contexts of the time, can it also explain why a caring, dedicated nurse would continue to risk the lives of her patients—patients she had known and followed for 15 years—after an accepted treatment for syphilis became available, in the mid-1940s? Yes, but this time Rivers needn’t be regarded as someone lucky enough to have a job but rather as a dedicated Tuskegee team member. If she was an entrenched member of the Tuskegee team when the decision was made to continue the study indefinitely, by the time penicillin was widely available she would have been a full-fledged “company woman.” Others in the study came and went over the years, but Rivers steadfastly remained. (She was replaced by Elizabeth Kennebrew in 1965 but continued to help Public Health Service physicians when they were in town and remained in contact with the men). 34 Rivers was a loyal employee who identified more with the researchers—the company—than she did with the subjects. Born and raised in rural Georgia,35 she may have come from the subjects’ world, but even at the beginning of the study she didn’t live in it anymore. Ten years out of nursing school, she was working steadily, both for Tuskegee and in her midwife-training capacity.36 She was a working professional. Smith refers to “Rivers and other black professionals,” and suggests that this professionalism may have “blinded them to the high price paid by poor, rural black men in the study.”37 To the scientific assistant part of Rivers, the poor, rural black men were subjects; to the nurse part of her they were patients. But more important, they were her job. She was working for an organization whose purpose was to gather data on untreated syphilis in black men; thus, it would have been more surprising if treatment had been provided. As some journalists realized at the time, given the study’s design, withholding penicillin was a foregone conclusion. Penicillin was withheld because all treatment was withheld.38 Darlene Clark Hine suggests that “[years] of conditioning and living in the South made it virtually impossible for Rivers to have rebelled against a white, male government doctor, the ultimate authority figure in her world.”39 Looking at Rivers as a loyal employee accounts for her subservience to the white government-official doctors in charge in a different way: They were her bosses, and as a good employee she did what the bosses told her to do. Telling moments from two interviews with Rivers suggest she strongly identified with the Tuskegee study team. She rarely spoke of her role in the scandal,40 and so publicly expressed few regrets. However, in a 1977 conversation with Helen Dibble and Daniel Williams, she allowed one: that the results of the study’s labor may have been lost. “[T]his was the thing that was so disturbing to me was that somehow all of the records of this study and the health department have been destroyed,” she told them.41 Another moment came in an interview with James Jones several years after a $10 million class-action lawsuit against the U.S. government was settled with the living participants of the study, in 1974.42 Jones and Rivers were driving through Macon County when Rivers saw a former study participant in a field and went out to say hello. When the man asked her why she had stopped coming by to see him, she told him, “You don’t get the money and Nurse Rivers too.”43
CONCLUSION:
Considering Rivers in the specific socioeconomic context in which she lived is one more way to make sense of her ongoing participation in what is now known as a deadly racist medical experiment perpetrated against Rivers’s own friends and patients. By first seeing her as fortunate to have secured a position with the study and then as a loyal team member later on, she escapes the harsher accusations of race traitor and coward; more important, it is consistent with her remaining in history the dedicated, caring nurse she professed to be. “Really and truly,” said Nurse Rivers, “when we were working with those people…that was the joy of my life.”44 Today she might simply be called a cog in the machine, but half a century ago she was someone lucky to be working in her chosen profession when nearly a quarter of the country was not working at all, someone who did not have the luxury of resigning in protest.
1 James H. Jones, Bad Blood: The Tuskegee Syphilis Experiment—A Tragedy of Race and Medicine (New York: The Free Press,
1981), p. 6 2 Susan M. Reverby, Examining Tuskegee: The Infamous Syphilis Study and Its Legacy (Chapel Hill: The University of North Carolina
Press, 2009), p. 168 3 Susan L. Smith, “Neither Victim Nor Villain: Eunice Rivers and Public Health Work,” Tuskegee’s Truths, ed. Susan M. Reverby
(Chapel Hill: The University of North Carolina Press), p. 349 4 David M. Kennedy, Freedom from Fear: Part I: The American People in the Great Depression (New York: Oxford University Press,
1999), p. 16 5 Ibid., p. 18 6 Ibid., p. 16-17 7 Ibid., p. 11-12
8 Ibid., p. 12 9 Recent Social Trends in the United States: Report of the President’s Research Committee on Social Trends (New York: McGraw-
Hill Book Company, Inc., 1933), p. 557 10 Ibid., p. 566 11 Wayne Flynt, “Poverty in Alabama” (Encyclopedia of Alabama, http:encyclopediaoflabama.org, November 2007) 12 Recent Social Trends, p. 570 13 Felix James, “The Tuskegee Institute Movable School, 1906-1923,” Agricultural History, July 1971: Vol.45, No. 3, p. 202 14Ibid., p. 206 15 Ibid., p. 208 16 Reverby, Examining Tuskegee, p. 170 17 Darlene Clark Hine, Black Women in White: Racial Conflict and Cooperation in the Nursing Profession 1890-1950 (Bloomington:
Indiana University Press, 1989), p. 92 18 Ibid., p. 101 19 Reverby, Examining Tuskegee, p. 170 20 Jones, Bad Blood, p. 102 21 Ibid., p. 6 22 Laurie interview; Eunice Rivers, Stanley H. Schuman, Lloyd Simpson, and Sidney Olansky, “The Twenty Years of Follow-up
Experience in a Long-Range Medical Study, Public Health Reports 68 (1953): 394, cited in Jones, Bad Blood, p. 163 23 “The U.S. Public Health Service Syphilis Study at Tuskegee” (Centers for Disease Control and Prevention,
www.cdc.gov/tuskegee) 24 Smith, “Neither Victim Nor Villain,” p. 354 25 Laurie interview, p. 167 26 Ibid., p. 11 27 Ibid 28 Robert VanGiezen, Albert E. Schwenk, “Compensation from Before World War I Through the Great Depression,” Compensation
and Working Conditions, Fall 2001 (Bureau of Labor Statistics, www.bls.gov/opub/cwc/cm20030124ar03p1.htm, posted Jan. 30,
2003) 29 Clark Hine, Black Women in White, p. 155 30 Jones, Bad Blood, p. 111 31 Ibid., p. 46 32 Smith, “Neither Victim Nor Villain,” p. 358 33 Jones, Bad Blood, p. 116 34 Reverby, Examining Tuskegee, p. 172 35 Ibid., p. 169 36 Ibid., p. 172 37 Smith, “Neither Victim Nor Villain,” p. 360 38 Jones, Bad Blood, p. 9 39 Clark Hine, Black Women in White, p. 156 40 Reverby, Examining Tuskegee, p. 168 41 Helen Dibble, Daniel Williams, “An Interview with Nurse Rivers,” Tuskegee’s Truths, ed. Reverby, p. 327 42 The U.S. Public Health Service Syphilis Study at Tuskegee: The Tuskegee Timeline” (Centers for Disease Control and
Prevention, www.cdc.gov/tuskegee) 43 James H. Jones to Susan M. Reverby, Personal Communication, July 7, 2004, cited in Reverby, Examining Tuskegee, p. 183 44 Jones, Bad Blood, p. 161

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1. What struck you most about the role Ellen plays as a care coordinator?
2. In your clinical experience thus far, can you describe a complex medical patient you have cared for that would have benefited from services similar to those Ellen has described? Explain why.
Lingos welcome to the Cure Coordination meet the professional podcast today. I’m really pleased to have. Ellen is our guest. She’s going to talk to us about her role as a cure for denator. Can you tell us? About your program and the types of patients you see. Sure. I’m the nurse practitioner for the Children’s Complex Care program, which is a small program that was started about six years ago to provide intensive medical care coordination for children who have multiple medical needs are hospital. Has a very high level of acuity as a teaching hospital, we see the sickest kids not only in the area but even some children who come from far away to be at our hospital. Some of those children have very specific diagnosis. Their children with a specific cardiac disease or children with a specific type of cancer, or perhaps children who need an organ transplant for each of those conditions. For each of those services, there’s a team that addresses. The comprehensive needs that that child met family has. However, there are many children who are cared for at hospitals like ours who have multiple concurrent medical problems. These might be children who were born very prematurely or might be children with genetic syndromes. These are children who have medical problems that have that affect multiple body systems. So for instance, we may have a child with a genetic syndrome who has cardiac disease and respiratory difficulty and has an immune deficiency and may also have difficulty eating the kids. We take care of require a lot of behind the scenes work and. That’s the reason that our program came about in recognition of the fact that there are a lot of just as well. There’s a lot of stuff on a lot of different levels that need to be done for children who have high levels of medical complexity, we do things on a lot of different levels to help the entire team. And when I say the team, I mean. The medical providers, the nursing providers, providers who care for the child in the community at home and in the school setting, and also the children and the family themselves. As part of that medical team. So we try to bring everybody together to help the the child in the family. Identify what their goals are and help meet those goals. What a great service can you give us? A couple of examples of the types of patients you care for and the role you play in their care. Oh gosh, we had a little fellow who came out of the hospital who had been here for many many months. Hadn’t really been home, had been back and forth between the hospital and a rehab facility, and he had, like, I don’t know, seven or eight appointments in the first three weeks. Here’s this mom trying to figure out. How to take care of a child who was very fragile and also add a lot of technology. A lot of our kids have feeding tubes and a good number of them rely on help breathing, which may be oxygen or what we call non invasive ventilation which is CPAP or BIPAP or even a tracheostomy and ventilator. And we have some kids with central lines which are semi permanent Ivs, so that’s a lot. And then there’s a matter of getting a kid getting any kid but getting a kid with all that equipment to the hospital. And just as this parent was trying to get her footing at home, we’re saying, OK, you have to come back two times next week and three times the week after that. Twice the week after that, and so one of the things that I can do is sit down and say, OK, this is really important now. This can wait a couple of weeks or this. I’m not sure if we can stall, but I have a Direct Line to this medical provider, so let me give him or her a call and or send a message to find out if we can delay. Or maybe it’s possible for you to see Gastro Enterology and from analogy on the same day. So that’s only one trip to the hospital. I work with a Community health worker who works very closely with the parents on helping them schedule appointments, but also helping them learn to schedule their own appointments, helping them with transportation which sometimes needs to be in an ambulatory, even an ambulance. And helping them set that up and also helping them learn to set that up so some of the things that we do are very nuts and bolts. Things help identify which appointments are most important, help the kids get here, help coordinate the Mondays and times that are actually feasible. I also do something that I fall hurting the cats. Which is bringing the different matter members of the medical team together. I just saw a little boy today. He’s not a little boy anymore. He’s a big boy. He’s 12 now, but I was remembering talking to his dad about one of his hospitalizations when the program was new and he was new to the program. He has pretty severe neurological impairment and was coming in for frequent pneumonias, so he would come into the hospital and they would treat the pneumonia and he would be here for a couple of weeks and he would get better and then it would happen again. So what we were able to do in the complex care program was bring a group of his medical providers together. To see what can we do to interrupt this cycle and we did a bunch of different things. We adjusted his epilepsy medicines because when he’s on too much medicine, he’s sleepy, which makes him more likely to aspirate when he’s done not enough medication, he’s more likely to seize, which makes him more likely to aspirate. So we did that. We also converted his feeding tube from a G tube feeding tube that goes directly to his stomach to a different kind of tube called the GJ tube that extends down into his intestine so that the feeding is going in. His formula is going in further down. Into his body and he is less likely to reflux contents up from his stomach and have that landed his lungs and cause pneumonia. And we also involve physical medicine and rehabilitation and arranged for him to get. Botox, like Botox like Botox, which we use in clinical settings as well to decrease his saliva production? Doing that combination of things was really successful in decreasing his hospitalization. It’s not eliminating them because he’s. A fragile kid and he’s gonna get sick. But we were able to bring the team together and discuss a a multifaceted approach to getting him more stable. Your patients are so complicated. I can see why care coordination is such an important part of their care, and I’m particularly struck by your advocacy for your patients and families and the way you work to collaborate with a diverse medical community that’s required to care for your patients. I can see that it has such a positive impact on everyone involved. It sounds like a lot of work, so I need to ask what is your typical caseload like? We have 53 kids on our caseload. There are some who I talked to their parents three times a week and there are some who honestly I haven’t talked to for three or four months. We find that when children come into the program, there’s a trajectory. There’s like a hump to get over and that make take. One or two months and that may take four or five months, but we find that with time we can identify what the big issues are for the child and family we can get to know the medical team and we can put some plans into place. Sometimes we find parents just don’t know who to call. If your kid has cardiac disease and respiratory disease and a feeding tube and they’re coughing and throwing up sometimes the parents really don’t know if they should be calling the cardiologist or the pulmonologist, or the gastroenterologist, or if they should be calling their primary care provider. So we help them figure that stuff. Out so we find that over a number of months that was a lot of handholding from our Community, health worker, and a lot of like I said, hurting the cats between me and the medical providers. We can get the kids and the families to a place of greater stability. We generally don’t make them better. These are kids with serious and life span limiting conditions and sometimes we can improve their health status with the goal of having them live for longer, but often what we’re doing is trying to make their lives and their parents lives easier. And more stable, reduce unplanned hospital admissions, for instance, which are extremely extremely stressful and disruptive. Some of our kids we can really get to a point of stability. We’ve had a couple who really kind of did get better. The nature of their condition was that that they they got better and didn’t need us. We have some who. Things are more under control there. Their parents have it down there. Providers have it down, so they need us much less, but we’ll still say stop by and see them when they’re in the hospital or do a periodic review of their appointments and make sure they’re up to date on everything. And then we unfortunately have some kids. Just condition is declining because they do have degenerative. Conditions and we have some kids who were just. Always gonna be very present on our radar because of the nature of what they have. It sounds like even though your caseload is high as well as their, your patient acuity that some of your patients and their families become increasingly capable of managing for the most part independently overtime, which is of course. The goal of many care coordination programs. What are the parts of your job that you like best? I am in the really lucky position of getting to spend time with my patients and families and knowing them overtime and the opportunity to follow children overtime and see them grow into that lab. And as important to me to see their families grow into velop. We see incredible beauty, we see. Parents who celebrate. These milestones in their children that another parent would have missed entirely, who just loved their children, exactly how they are. I’ve just seen the great pain and great beauty coexist. I think people kind of think that good things and bad things are on a scale, and they pull out. You know they. They they. They equalize, and that’s not what happens. It’s not like a a good thing makes up for a bad thing or a bad thing cancels out a good thing, but I do see how parents live with great pain and children, parents and children live with great pain, but also great talents and great beauty, and that’s great. So as a palliative care provider, I completely agree. What parts of your job do you find challenging? Our medical system is very, very good at high tech stuff. It’s likes to fix things. It likes high tech solutions for fixing things. It has infrastructure for high tech solutions to things it doesn’t have infrastructure for care. The emotional toll and the physical toll on families is unfathomable. The other thing is that, like I feel like the hospital system where you know you’re admitted to like a generalist service and then you get various consults coming in. That’s a system that was developed, you know. However, many years ago it was developed decades and decades ago, and it worked. If you had to keep a patient who came in for something and you just needed to call a cardiology konsult and it was the the one hospital provider attending was overseeing the case and consulting with one specialist. But when you have a kid. In the hospital and four different services have been called to consult, and they’re all going in and out of the room. We’re communicating by text message or relying on people to read our notes in the chart. I liken it to, you know, a family built a house and it’s like a nice little house and they raise their children there and then the. I’ll just Child gets married and they build an addition onto the house. Then the next child gets married and you know, in some cultures there’s like these. These family houses, grown and grown and grown over the years, and it’s wonderful ’cause the whole families living together. But if you were going to build a house for that many people, you wouldn’t have built it the way that we have built our system. And so it’s in the same way that it’s great to have the whole family together. It’s great to have the expertise of so many different people, but how do you pull that together in a coherent system? I work on bridging that gap, but sometimes I feel like the whole system needs to be blown up and and recreated from scratch. What a great analogy. That’s my analogy for the week. OK, So what do you see as the most important skills for someone that does your job? I think you gotta be organized and which I I laugh when I say that because because people who know me and my personal life don’t think of me as the most organized person. But I think that. Organization might not be an innate talent it it originate quality, but it’s something that you can systems in place for. So we’ve been thinking a lot about that. We have a little spreadsheet for each kid where it has the kids name, and then it has all the different specialties the kids have ever seen. In their last appointment in their next appointment that can sink into a calendar week, we set it up on Excel. I didn’t set it up. Somebody set it up on Excel so that you can sync so I can know all the kids who are coming in on a given day, and so I can. Also every time I go to talk to that parent by. Check you know, I I I have like a reference point so I just wanna ask real quick so does that mean then you see patients primarily in the hospital setting and then your community health worker sees patients in their homes? We actually don’t do home visits. I would love if we had have the bandwidth we don’t have clinic time. We kind of follow our kids where they are so we do a lot of work by phone and some of that’s reactive, meaning that the parents call and they have a specific question and we answer that specific question and if it’s not a crisis we also try to stay. And while we have you. And checking on other thing, this was the medication picked up gicu haven’t been too. This specialist in a little while, is there a reason for that and some of that is proactive where we’re you know, well, we’ll call families on a on a regular schedule and we’ll check to make sure they have all their medications, all their supplies. If they get home, nursing or home. Other sorts of Home Care Services. Stats in place. Well, when they’re admitted to the hospital will stop up and see them. Sometimes I’ll round with the teens. Sometimes I’ll arrange a either team meeting just with the medical team or a family meeting with medical team and the family. And sometimes it’s just kind of pie. You know, we’ll just go in to say hello and and there isn’t a particular issue. That the medical team needs us for, but we just, you know, check in with our families to maintain that relationship. And similarly when they come in for outpatient appointments because we have that set up with the cell spreadsheet. I all know who’s coming in on every any given day, and I can wander by and see them. And sometimes one of the somebody in cardiology. That said I was coming by to see a patient, they said. Is there problem? And I said no, I’m just saying hello. She said you’re doing howdy rounds and I love that yeah I was just going to say hi and that’s just a good way of us building trust in continuity with the families. Sometimes I’ll touch bases with the family just to make sure they’re up to date on their appointments and their nursing and their meds. And I’ll do that in. Person while they’re here, sometimes I’ll address another issue I mentioned that I worked in GI and so if so I know that. So if the kids having like a problem with their GPU, Venice coming into neurology, sometimes I’ll stop up to look at that. But another thing that I sometimes do is I’ll go to appointments either because. I think the parent doesn’t really understand why they’re being sent to the specialist or they have a complicated medical history and I wanna. Be able to give the specialists in background or because I think that the parent doesn’t really understand why they’re going to the visit. You know, I’m at the point where I know most of the clinicians here, and I know this person might not be the most clear explainer, and so I can go and be a second set of ears or. You know, sometimes the parent knows exactly why they’re there. I have a mother who hates to go to the neurologist because her child has a static condition. She’s not getting better and it always feels like bad news. And so if I’m able, if I’m free, I’ll just go because you know, we’ve known each other for a long time and it’s hard for her to be there. You have a great job. So how do you see the future of programs like yours as a field? I don’t have any insight into where the field is developing, but. It’s very clear to me that as. Medical technology advances and as medical care gets more and more complicated and there are more and more players than care, coordination is going to be. More important than ever, because it’s just too complicated. It’s just too complicated. There’s too many moving parts to keep track of. There is, in my opinion, too much attention to the high tech and the breakthrough and the keeping people alive. For longer and have that be the default, more end better and families are struggling in social situations. The most common question I get asked is oh, is there something like that for older people? That’s just what I need for my mother. That’s just what I need. For my father. And of course you know the answer to that question is yes, there are all kinds of care coordination programs for older adults. So I think on that note we’ll wrap up. Thanks again for taking the time to talk about the very important work that you do for these children and their families and bringing the role of care coordinator to life for the students. That’s the end of this podcast. Please complete the discussion board below.

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MULTI 3 EXAM 1
A 40-year-old woman has high vaginal bleeding. Which question is the priority in evaluating the client’s chief complaints?
“Is the bleeding related to the menstrual cycle or intercourse”
“Are you having any sensations of pain or cramps”
“Are you sexually active and do you use oral contraceptives?”
“Are you feeling weak, dizzy or lightheaded?”
A nurse is caring for a 50-year-old male patient presently diagnosed with erectile dysfunction (ED). Which of the following is a possible cause of ED?
Hypertension week 2
Sexually transmitted diseases
Opioid overuse
Caffeine consumption
Which of the following interventions would meet the multidimensional needs of a 45-year-old male who was recently diagnosed with testicular cancer (Select all that apply)?
Consult the dietician for cultural dietary needs
Conduct a cultural assessment
Provide a psychosocial assessment
Provide emotional and spiritual support
Offer client family-centered care
A nurse is providing education at a health fair regarding breast cancer. Which of the following informational brochures would be more beneficial to distribute to the participants?
Self-breast examination
Diet modification
Stress reductions
Exercise regimen
The nurse knows to include which of the following when teaching a client about the common cause of pyelonephritis?
Urinary retention and ascending infection of the urinary tract
Delayed voiding
Renal calculi
Previous UTI
A nurse is caring for a 32-year-old female with a history of breast cancer. Which of the following should be included in the client education?
Annual mammography
Clinical breast examination every 2 years
Herbal supplements
Preventive screening to begin at the age of 45
A client is emotionally upset after the diagnosis of endometrial cancer. What action by the nurse is best?
Leave the client alone for an extended period for reflection time
Create an atmosphere that supports acceptance and discussion
Tell the client that her emotional response is unacceptable
Limit visits from family and friends
A nurse is providing education to a female client regarding cystitis. Which of the following should the nurse include in the client education?
Avoid the use of feminine sprays
Increase frequency of douching
Utilize a diaphragm for birth control
Wipe perineum from back to front
The nurse is teaching a group of women about the prevention of toxic shock syndrome. What preventive measure does the nurse include in the teaching? (Select all that apply)
‘Avoid the use of high absorbency tampons”
“Use sanitary napkins at night”
“Avoid using internal contraceptives”
“Have your partner avoid using condoms”
“Change tampons every 8 hours”
A nurse is caring for a 58-year-old male who recently underwent an open radical prostatectomy. Which of the following nursing interventions would be appropriate for the client? (Select all that apply)
Pain management
Venous thromboembolism prevention 1484
Monitor intake and output
Maintain bedrest
Monitor for signs of infection
Based on American Cancer Society recommendations, what does the nurse teach the patient about screening for prostate cancer?
Beginning at age 30, all men should have an annual digital rectal examination
Men that have a prostate specific antigen (PSA) test done do not require a digital rectal examination
Men with multiple first-degree young relatives with prostate cancer at an early age should discuss screening with their healthcare providers at age 40
Asian-American men should start screening at age 55years
Which of the following should the nurse include in the education fir a client who recently underwent cervical ablation for cervical cancer?
Resume tampons in 24hours
Do not douche
Tub baths are preferred over showers
Resume sexual intercourse in one week
A nurse is caring for a 56-year-old male patient who was recently diagnosed with benign prostatic hyperplasia. Which of the following is a common assessment finding related to this disorder?
Painful urination
Penile discharge
Difficulty starting urine stream
Increased daytime urination
The client is being treated for both BPH and hypertension. Which alpha-blocker does the nurse anticipates will be prescribed for the client?
Doxazocin alpha-blockers
Finasteride 5-alpha reductase inhibitors
Dutasteride 5-alpa reductase inhibitors
Sildenafil phosphodiesterase (PDE) inhibitors
A nurse is caring for a 30-year-old female client that has been diagnosed with uterine leiomyoma. What the nurse expects to see as the client’s presenting chief complaints?
Feeling of vaginal pressure
Heavy vaginal bleeding
Intermittent pain
Urinary changes
Which of the following is considered a risk factor for the development of breast cancer?
Age
Race
Activity
Genetics
The nurse knows that which of the following is considered a late sign of prostate cancer?
Difficulty starting urination
Hematuria
Frequent bladder infections
Urinary retention
A client experiencing secondary syphilis may experience all of the following signs and symptoms except? Antibiotics
Fever
Headache
Muscle aches
Diarrhea
A nurse is caring for a client who was recently diagnosed with acute kidney injury. Which of the following are possible causes of acute kidney injury due to perfusion issues?
Bladder cancer
Myocardial infarction
Kidney stones
Lupus
A nurse is caring for a client who was recently diagnosed with chronic renal failure. Which of the following is a treatment option for a client with renal failure?
Fluid resuscitation
Diuretics
Dialysis
Diet rich in potassium and magnesium
You are providing discharge instructions to a client who is prescribed antibiotics for the treatment of sexually transmitted disease. Which of the following should you include in the medication administration?
Refrain from sex for at least 7days 2
Take antacids prior to taking the antibiotics
Take medication prior to bed
Take medication with a high-fat meal
Which of the following are treatment options for a client with renal cell carcinoma who only has one kidney and is not a candidate for surgery?
Microwave ablation
Chemotherapy
Nephrectomy
Radiation
The nurse knows to include which of the following when teaching a client about the most common cause of acute pyelonephritis?
Urinary retention and ascending infection of the urinary tract
Delayed voiding
Renal calculi
previous UTI
Decline as a new diagnosis of testicular cancer the nurse recognise which of the following is the sign of testicular cancer
painful enlargement of the testicle
painless enlargement of the testicle
painless shrinking of the testicle
painful shrinking of the testicle
Dino’s is providing information to the client who has genital apes. What priority assessment would be the nurse so concern
after a diagnosis of hsv minus 2, there are likely to be true to theory outbreak during the
transmission of genital apes can occur from a partner who does not have a
a apps simplex virus minus one hsv minus one genita infection can occur with aura genitor Contacts
janitor apes simply virus minus two is more common in women than in men
During a routine prenatal examination, a pregnant woman’s urine is found to contain glucose. What does this finding indicate to the nurse?
The patient should have further testing for gestational diabetes.
The patient should have a lover enzyme panel completed
The patient is eating excessive calories
It is because of a decrease in GFR
The nurse is caring for a male who was recently diagnosed with benign prostatic hypertrophy. Which of the following medications should the nurse instruct the client to avoid?
Calcium channel blockers
Anticholinergic
Beta-blockers
Nonsteroidal anti-inflammatory drugs
A 58-year-old female presents to the Dr’s office for a checkup. She communicated that she has not previously had any preventive screening. Which of the following would increase her risk of preventing breast cancer?
Having her first child at age 25
Dense breasts
Low socioeconomic status
Stress
Which of the following clients are at risk of developing genital warts?
Those who have unprotected sex
Drug abusers
Individuals with opioid addictions
Males/females in many relationships
Jane is a 28-year-old female who presented to the emergency room with genital warts lesion. She was diagnosed with genital herpes. Which of the following nursing interventions would be applicable to this diagnosis?
NSAIDS
Limit urinary frequency
Application of heat
Douche administration
The obese 54-year-old client describes excessive menstrual bleeding that occurs approximately every 10 days. The nurse prepares the client for which diagnostic test that is used to evaluate for endometrial cancer?
Bimanual pelvic examination
Transvaginal ultrasound
Sonohysterography
Endometrial biopsy
A nurse is caring for a client with polycystic kidney disease. The nurse anticipates all of the following interventions or treatment options except which of the following?
Pain management
Blood transfusion
Blood pressure control
Genetic counseling
A nurse is caring for a 30-year-old male client recently diagnosed with testicular cancer. Which of the following nursing intervention should be included as a priority for the client?
Education on options for sperm banking
Education of likelihood of testicular removal
Nutritional assessment
Spiritual assessment
A client with uterine leiomyoma reports a feeling of pelvic pressure, constipation, urinary frequency and says, “I can’t button my pants anymore”. What does the nurse assess further to evaluate specific to the client’s complaint?
Fluid imbalance
Abdominal distension or enlargement
Bowel or bladder incontinence
Vagina bleeding or discharge
the nurse has viewed the lab result of the client being treated for nephrotic syndrome. And has noted a normal glomerular filtration rate (GFR). Which of the following dietary interventions does the nurse educates the client to incorporate into their diet?
Increase the intake of vitamin K to decrease the risk of thrombus
Decrease fluid intake because the kidneys are retaining an excessive amount of fluid
Increase sodium intake to help prevent hypotension secondary to fluid loss
Ensure adequate protein intake in the diet
Which of the following are common assessment findings for a client with pyelonephritis? (Select all that apply)
Inability to void
Abdominal distension
Foul-smelling urine
Nocturia
Flank pain
Linda is a 45-year-old female that reported to the doctor’s office with the concern regarding finding a lump during her monthly self-breast examination. She denies having a family history of breast cancer. During her physical examination, the provider notes no visual abnormalities of the breast, normal nipples, no nipples and no discharge. The nurse anticipates the provider will order what test?
Mammogram
Genetic testing for breast cancer
Ultrasound
Biopsy
A nurse is caring for a client who is status post-nephrectomy secondary to renal cell carcinoma. Which of the following nursing interventions is the highest priority in the postoperative management of the client?
Monitoring for hemorrhage
Pain management
Coughing and deep breathing
Early ambulation
A nurse is caring for a client who has recently been diagnosed with erectile dysfunction. Which of the following are treatment options for this disorder?
Phosphodiesterase-5 (PDE-5) inhibitor
Exercise
Blood pressure control
Penile transplant
A nurse is caring for a client who has a diagnosis of urolithiasis. Which of the following findings should the nurse expect in this male client? (select all that apply)
Flank pain
Bradycardia
Pain radiating to the shoulder
Nausea and vomiting
Testicular or scrotal pain
A nurse is caring for a client who presented to the emergency room with the complaints of fatigue, hematuria, and weight loss. Upon physical examination, the client’s blood pressure is 190/100mmHg with positive jugular vein distension and lower extremity edema are present. A urinalysis revealed the presence of red blood cells and protein, serum, BUN and creatinine are elevated. Based on these findings, the provider suspects the client has acute glomerulonephritis. Which of the following test would the nurse expects the provider to order?
CT scan of the abdomen and pelvis
24-hour urine collection
AST & ALT
Serum potassium
During the first 24hours after transurethral resection of the prostate (TURP), what is the priority assessment concern in the nursing care plan?
Hemorrhage
Infection
Hydronephrosis
Confusion
A nurse is teaching an older client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?
“Have an eye examination once per year”
“Examine your feet carefully everyday”
“wear compression stockings daily”
“Maintain stable blood glucose levels”
The nurse educates a teenager on the benefits of receiving the human papillomavirus (HPV) vaccine as protection against which type of cancer?
Endometrial cancer
Cervical cancer
Ovarian cancer
Uterine cancer
What does the nurse include in the discharge teaching for a woman who had a total abdominal hysterectomy for endometrial cancer?
Do not lift anything heavier than 20lb/ less than 15
Sexual activity may be resumed in 2 to 3 weeks
Gradually increase walking as exercise but stop before becoming fatigued 1463
Wait for 24hours after discharge to begin driving
A nurse is providing education to a client diagnosed with urinary incontinence. Which of the following should be included in the client education?
Avoid fluids and drinks that contain caffeine
Increase fluid intake
Increase cranberry juice consumption
Avoid salt intake
Sue, a 32-year-old female presents to the physician’s office with complaint of heavy menstrual bleeding and prolonged periods. She states that this has been going on for approximately six months. She avoided coming to the Doctor’s office because of fear of possible cancer. Which of the following will be performed based on patient’s symptoms?
Liver function test
Pelvic testing
Fecal occult blood test
Genetic examination
The nurse includes which of the following in self-management teaching for a client diagnosed with vulvovaginitis?
Wear cotton underwear 1471
Wear tight-fitting clothing for support
Use feminine sprays
Wipe from front to back only after bowel movements
A client with urinary tract infection has just been diagnosed with acute kidney injury. The physician ordered lab work to be done. The nurse expects which of the following abnormal labs to be present in this client with acute kidney injury?
Arterial HCO3-34, 22 to 28
K- 5.7; 3.6 to 5.2. Mg- 3.1 1.7 to 2.2
Creatinine – 0.9; BUN- 12
Phosphorus- 2.2; calcium- 12
A nurse is caring for a client comma home self identifies as a female End also not as sex is male which of the following most the nurse take note
Identify and address the client only by their natural sex gender
demonstrates respect’s for clients non-conforming gender identity
facilitate access to appropriate healthcare providers
be aware of individualised healthcare needs
A client is preparing for discharge following an open radical prostatectomy procedure. which of the following would the nurse not include in the discharge teaching?
use a stool stuff nuts will avoid straining with bowel movements
lift less than 15 lab for the next 6 hours
shower for the first few weeks rather than soaking in the bath
pulled this terrible stripe of the incision when they begin lifting on the edge
The nurse is assessing a client who has a translator resection of the prostate procedure which of which knew finding is the greatest concern?
Client urine output looks like ketchup
clients report pain to be 4 out of 10
client has urine output or 50CC per hour
client has an indwelling catheter and report urge to void
Based on American Cancer society recommendations, what does the nurse teach the patient about screening for prostate cancer?
Beginning at age taxi all men should have an annual digital rectal examination
men that have a prostate specific antigen blood test does not require a digital rectal exam
men with multiple first-degree young relatives with prostate cancer he at early age show discuss screening with their healthcare provider at age 40
Asian -American men should start screaming at 55 years of age
Did nurse is providing education regarding the risks of chlamydia infection.
infertility
pelvic inflammatory disease
ectopic pregnancy
recurring outbreaks
An older adult client is being treated for Endometrium cancer. which of the following is the nurse expect to find in the clients record that was?
pelvic pain
nausea and anorexia
postmenopausal uterine bleeding
vaginal discharge or bleeding
A nurse is caring for a client who has recently been diagnosed with erectile dysfunction. Which of the following are treatment options for this disorder?
Phosphodiesterase-5 (PDE-5) inhibitor
Exercise
Blood pressure control
Penile transplant
A nurse is preparing to administer lisinopril 30 mg PO now. Available is lisinopril 20 mg/tablet. How many tablet(s) should the nurse administer?
0.5
1
1.5
2
The nurse is reviewing the laboratory results for a client with metastasis of prostate cancer to the bone. Which elevated level does the nurse expect to see?
Alpha-fetoprotein
Blood urea nitrogen
Serum alkaline phosphatase
Serum creatinine
You are caring for a client who was diagnosed with syphilis. Which of the following medications are used for treatment?
Benzathine penicillin G
Vancomycin
Ampicillin
Gentamycin
Which of the following is not considered a risk factor for the development of prostate cancer?
Age
Race
Activity level
Genetics
A medication order states administer furosemide 30 mg IM stat. Available is furosemide 100 mg/10 mL. How many mL should the nurse administer?
1.5
2
3
6

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51. A nurse is caring for an older adult client who has hypothyroidism. Which of the following findings should the nurse expect? 1. Bradycardia 2. Weight-loss 3. Increased temperature 4. Restlessness 52. A nurse is contributing to the plan of care or a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care? 1. Administer antibiotic therapy before culturing the client’s wound. 2. Instruct visitors to perform hand hygiene for 5 seconds after leaving the client’s room. 3. Discard soiled wound care supplies in a trash receptacle outside the client’s room. 4. Place the client in a private room with a private bathroom. 53. A nurse is assisting a provider with removing a client´s lower-leg cast. Which of the following statements by the nurse is appropriate? 1. ´´You should avoid elevating your leg while sitting.´´ 2. ´´You can expect your leg muscles to look a little swollen.´´ 3. ´´You should hold still to prevent injury to your skin.´´ 4. ´´You can expect to feel pressure when we cut the cast.´´ 54. A nurse is reinforcing teaching with a client and her partner about performing chest physiotherapy at home. Which of the following statements by the client indicates an understanding of the teaching? 1. ´´I will need to change my position multiple times during the procedure.´´ 2. ´´I will wear a sweatshirt during the procedure.´´ 3. ´´I should eat a small meal prior to the procedure.´´ 4. ´´I should take a prescribed bronchodilator following the procedure.´´ 55. A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first? 1. Offer an analgesic medication. 2. Request the client to be NPO. 3. Administer a glycerine suppository. 4. Ambulate the client in the hallway. 56. A nurse is reviewing the results of a client´s fecal occult blood screening test. Which of the following findings from the client’s history should the nurse identify as potentially causing a false-positive result? 1. The client has a history of breast cancer. 2. The client consumed citrus juice 3 days before the test. 3. The client takes ibuprofen for headaches. 4. The client had a hemorrhoidectomy 1 year ago. 57. A nurse is reinforcing teaching about home safety measures with a client who is visually impaired. Which of the following instructions should the nurse include? 1. Leave doors slightly ajar. 2. Use low-wattage light bulbs. 3. Place throw rugs over electrical cords. 4. Mark the edges of steps. 58. A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take? 1. Cover the paid prior to use. 2. Fill the pad with sterile water. 3. Use safety pins to secure the pad in place. 4. Apply the pad for 45 min at a time. 59. A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements by the client indicates an understanding of the teaching? 1. ´´I should place an aspirin in the pouch to eliminate odor.´´ 2. ´´I should avoid broccoli and chewing gum.´´ 3. ´´I should clean around the stoma with moisturizing soap.´´ 4. ´´I should decrease the amount of fresh fruit in my diet.´´ 60. A nurse is supervising an assistive personnel(AP) providing care for a group of clients. For which of the following actions should the nurse intervene? 1. The AP plans to assist a client who had hip arthroplasty to a bedside commode. 2. The AP plans to turn a client who has paraplegia every 2 hr. 3. The AP prepares to provide wound irrigation to a client who has a decubitus ulcer. 4. The AP prepares to obtain the blood pressure of a client who had peritoneal dialysis. 61. A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take? 1. Implement contact precautions. 2. Maintain the client in a supine position. 3. Apply petroleum jelly to the client´s nares. 4. Initiate precautions. 62. A nurse is reinforcing teaching with a client who has heart failure and a new prescription for furosemide. The nurse should instruct the client to monitor for which of the following adverse effects? 1. Agitation 2. Ringing in ears 3. Rhinitis 4. Metallic taste 63. A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection? 1. Changed mental status 2. Diminished reflexes 3. WBC count 9,000/mm3 4. Temperature 37.3 degrees celsius(99.1 degrees Fahrenheit) 64. A nurse is reinforcing teaching with a group of clients who are at risk for coronary heart disease due to hypercholesterolemia. Which of the following information should the nurse include in the teaching? 1. Include fish in the diet two times per week. 2. Increase intake of dairy products 3. Limit servings of meat per meal to 113 to 170 g(4 to 6 oz). 4. Cook with coconut oil. 65. A nurse is preparing a client who has acute appendicitis for surgery. Which of the following actions should the nurse take? 1. Apply a heat pack to the client´s lower abdomen. 2. Administer an enema to the client. 3. Give the client a clear liquid diet. 4. Place the client in semi-Fowler’s position. 66. A nurse on a medical-surgical unit is caring for an older adult client who has developed due to a urinary tract infection. A member of the client’s family tells the nurse not to perform any ´´heroic measures´´ to keep the client alive. Which of the following responses by the nurse is appropriate? 1. ´´Ýou should contact the client’s attorney to document your wished legally.´´ 2. ´´Why do you believe treatment would not benefit the client?´´ 3. ´´The client’s condition is not critical enough to discuss these issues.´´ 4. ´´Let me check the client’s medical record for advance directives.´´ 67. A nurse is interpreting the results of a tuberculin skin test for a group of clients who received this test 48 hr ago. Which of the following clients should the nurse identify as having a positive test result? 1. A client whose injection site is scabbed. 2. A client whose injection site has an elevated area measuring 15 mm. 3. A client whose injection site is ecchymotic 4. A client whose injection site is firm and measures 3 mm. 68. A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema? 1. Keep both arms below the level of the client’s heart. 2. Obtain blood pressure readings using the client’s right arm. 3. Limit range-of-motion exercises with the affected arm. 4. Use the client’s left arm to obtain blood samples. 69. A nurse is collecting data from a female client who is postmenpausal. Which of the following should the nurse identify as a risk factor for the development of osteoporosis? 1. Long-term use of prednisone 2. Monthly vitamin B12 injections 3. Congenital heart murmur 4. History of kidney stones 70. A nurse is reviewing a client’s medical record. Which of the following findings is the priority for the nurse to report? 1. Urine output 200 mL/8hr 2. Potassium level 6.2 mEq/L 3. Abnormal hepatoiminodiacetic acid(HIDA) scan 4. A client’s rating of ear pain as 5 on a scale from 0 to 10. 71. A nurse is caring for a client who has a new diagnosis of tuberculosis(TB). The client asks the nurse why she needs to take four different anti tuberculosis medications. Which of the following replies should the nurse make? 1. ´´Taking several anti tuberculosis medications will protect your liver from toxic effects.´´ 2. ´´People who have a severe form of TB need several anti tuberculosis medications, but those who have less severe TB need just one medication.´´ 3. Adverse effects occur more often and are more severe when you take only one anti tuberculosis medication.´´ 4. ´´The organism that causes TB becomes resistant to anti tuberculosis medications when you only take one medication.´´ 72. A nurse is assisting with the plan of care or an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care? 1. Monitor the client for weight loss. 2. Check the client for increased hypopigmentation under the patch. 3. Advise the client about increased dry mouth. 4. Inform the client of the adverse effect of diarrhea. 74. A nurse is reinforcing teaching with a client who is postoperative following a tympanoplasty. Which of the following information should the nurse include? 1. Close mouth when sneezing. 2. Resume exercising in 10 days. 3. Plan to shampoo hair in 1 week. 4. Drink fluids through a straw. 75. A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm3. Which of the interventions should the nurse take? 1. Decrease the client’s protein intake. 2. Encourage the client to eat a diet rich in whole grains. 3. Cleanse the client’s toothbrush with hydrogen peroxide. 4. Use a disposable razor to shave. 76. A nurse is assisting with the care of a client who is postoperative and has received fentanyl for pain management. In the event the client develops respiratory depression, the nurse should make sure that which of the following medications is available to administer? 1. Atropine 2. Naloxone 3. Flumazenil 4. Acetylcysteine 77. A nurse is reinforcing teaching with a client who has COPD and reports shortness of breath and little appetite. Which of the following instructions should the nurse include the teaching? 1. Eliminate dairy products. 2. Eat lighter, low-calorie foods first. 3. Limit fluid intake during meals. 4. Consume three regular meals daily. 78. A nurse is caring for a client who had a colon resection 2 days ago. When entering the client’s room, the nurse sees a protrusion of tissue from the incision. Which of the following is the appropriate nursing intervention? 1. Place the client on her left side. 2. Place the client in Trendelenburg position. 3. Cover the site with a sterile, saline-soaked dressing. 4. Cover the wound with a dry, sterile dressing. 79. A nurse is caring for a client who has chronic kidney disease. Which of the following interventions is appropriate? 1. Administer NSAIDs for discomfort. 2. Obtain the client’s daily weight. 3. Monitor the client for hypokalemia. 4. Offer the client a high-protein diet. 80. A nurse is preparing to obtain a postprandial blood glucose level from a client who has diabetes mellitus. Which of the following actions should the nurse take? 1. Hold the client’s finger in a dependent position. 2. Clean the client’s finger with hexachlorophene. 3. Apply the first drop of blood to the test strip. 4. Prick the central tip of the client’s finger. 81. A nurse is reinforcing discharge teaching with a client regarding self-administration of regular insulin. Which of the following instructions should the nurse include? 1. Plan to eat a snake 6 hr after insulin administration. 2. Warm the vial to dissolve any crystals that develop. 3. Store opened insulin vials at room temperature for up to 4 weeks. 4. Keep unopened insulin vials in the freezer. 83. A nurse is reinforcing discharge instructions with a client who is taking oral iron supplementation for anemia. Which of th4e following statements by the client demonstrates an understanding of the teaching? 1. ´´ I should notify my doctor if my stools turn black.´´ 2. ´´I should drink my liquid iron supplement undiluted.´´ 3. ´´I should take my supplement with an antacid to prevent an upset stomach.´´ 4. ´´I should increase my fiber intake while taking this supplement.´´ 84. A nurse is providing directions to an assistive personnel about moving a client up in bed. Which of the following statements should the nurse include? 1. ´´Place a pillow under the client’s head prior to repositioning.´´ 2. ´´Face in the direction of the client’s movements.´´ 3. ´´Keep your feet close together while moving the client.´´ 4. ´´Move the client’s arms to his sides prior to repositioning.´´ 85. A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take? 1. Replace the unit when the drainage chamber is full. 2. Clamp the tube for 30 min every 8 hr. 3. Monitor for at least 150 mL of drainage every hour. 4. Pin the tubing to the client’s bed sheets. 86. A nurse is providing care for a client who has hemophilia and is bleeding from a small laceration on his arm. After applying a sterile dressing, which of the following actions should the nurse take next? 1. Check whether the bleeding has stopped. 2. Maintain direct pressure over the site. 3. Obtain a radial pulse. 4. Reinforce the dressing over the site. 87. A nurse is reinforcing teaching with a client who has ovarian cancer and will receive chemotherapy through a peripherally inserted central catheter(PICC). Which of the following statements by the client indicates an understanding of the teaching? 1. ´´It’s okay to get the device wet when I shower.´´ 2. ´´I will wear an arm immobilizer to prevent dislodgement of this device.´´ 3. ´´I should pull the dressing away from the insertion site when I change it.´´ 4. ´´I will monitor my temperature for fever while I have this device.´´ 88. A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan? 1. Apply foam handles to the client’s eating utensils. 2. Have an assistive personnel feed the client. 3. Obtain a referral for physical therapy. 89. A nurse is reinforcing teaching with a client who has psoriasis. Which of the following treatment options should the nurse include in the teaching? 1. Oil-based ointment 2. Benzoyl peroxide 3. Phototherapy 4. Dermabrasion 90. A nurse is collecting data from a client who had a long arm cast applied 2 hr ago. Which of the following findings of the affected extremity should the nurse report to the provider? 1. The client’s fingers are cool to the touch. 2. The client´s capillary refill is 3 seconds. 3. The client reports increased pain at the area of the fracture. 4. The client reports severe itching under the cast. 91. A nurse is collecting data from a client who has Graves´ disease. Which of the following images should the nurse identify as an indication that the client is experiencing exophthalmos? 92. A nurse is preparing a client for a colposcopy following an abnormal Papanicolaou test. Which of the following actions should the nurse take? 1. Place the client in the Sims´ position. 2. Instruct the client to avoid using tampons following the procedure. 3. Reinforce teaching that the procedure involves dilation of the cervix. 4. Instill a vaginal cream prior to the procedure. 93. A nurse in a long-term care facility is collecting data from an older adult client. Which of the following findings indicates that the client might be dehydrated? 1. Recent onset of confusion 2. Decrease in pulse rate 3. Increase in blood pressure 4. Cool, clammy skin 94. A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan of care? 1. Instruct the client to shave with a disposable razor. 2. Initiate protective isolation for the client. 3. Administer ibuprofen for mild headache. 4. Check the client for ecchymosis. 95. A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider? 1. Ammonia 55 mcg/dt. 2. Bilirubin 1.0 mg/dL 3. Aspartate aminotransferase 34 units/L 4. Platelets 60,000/mm3 96. A nurse is caring for a client who is experiencing a generalized tonic-clonic seizure. Which of the following actions should the nurse take? 1. Apply restraints to the client 2. Place the client in the prone position 3. Insert a tongue blade into the client’s mouth 4. Administer an IV bolus of lorazepam 97. A nurse is caring for a client who is postoperative following a total thyroidectomy for hyperthyroidism. Which of the following findings should the nurse identify as the priority? 1. Moderate amount of serosanguineous drainage on dressings. 2. Report of a sore throat. 3. Serum calcium level 9.2 mg/dL. 4. Oral temperature 39 degrees celsius(102.2 degrees Fahrenheit). 98. A nurse on a medical-surgical unit has just received change-of-shift report for four clients. Which of the following tasks should the nurse assign to an assistive personnel? 1. Reinserting an NG tube for a client who requires gastric decompression. 2. Performing a closed catheter irrigation for a client who is postoperative. 3. Bathing a client who has hemiparesis following a stroke 4. Showing a client who has a new colostomy how to empty the pouch 99. A nurse is assisting with discharge teaching for a client who requires oropharyngeal suctioning at home. The nurse should ensure that which of the following equipment is available for use at home? 1. Oropharyngeal airway 2. Yankauer catheter 3. Water-soluble lubricant 4. Sterile gloves 100. A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following client statements indicates an understanding of the teaching? 1. ´´I should round the corners of my toenails with a nail file to prevent ingrown nails.´´ 2. ´´I should use my wrist to test the temperature of the water before bathing. ´´ 3. ´´I should apply a heating pad to my feet every night to help with circulation.´´ 4. ´´I should put lotion between my toes every day to prevent dryness and cracking.´´

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Inpatient: A Psychiatric Story
Day 1
You’ve spent a week lying in bed, getting up intermittently to feed yourself. When the phone rings, you ignore it. You don’t know if you still have a job, and you don’t particularly care either. The world is too draining for that.
You lost a friend two weeks ago. Your cat, Cassandra, passed away. There were signs of sickness the night before, but you decided you would take her to the vet the following day if it still looked bad.
She died in the middle of the night.
You’re in a spiral of indifference and hate, as even the most basic of your routines – waking up, checking her food and water – have been interrupted. Occasionally you move in the direction of her food, only to remember. You’ve spent days upon days remembering.
Your feelings are too intense to rely on their messages. You’ve lost hope. You’re suicidal, and the last place to turn is a hospital.
You pick a hospital. Somewhere you aren’t known – somewhere you haven’t been before. You call a taxi.
You’re there.
The walls are adorned with large colourful murals. One section is a picturesque landscape with the word “RECOVERY” in a bold font. You can barely remember the events of the day or how you made it here.
The receptionist sits behind a glass window, and she looks to you. “How may I help you?”
You stutter for a moment, struggling to find words. “I, um, need to talk to a doctor.”
You exchange basic information and provide proof of health insurance. She verifies your address and emergency contacts. A large man takes your bag and leads you to an isolated area in the hospital. He wears a blue shirt with “Protection Services” written on the back. The security guard raises his ID to a sensor beside the wide door. It beeps, and he opens the door. You walk in, and it shuts behind you.
You just arrived in the ER. You know you’re going to wait a while – but you don’t know how long.
The room is bland and empty with many rows of chairs. Each chair is divided by an arm rest. A single TV on the wall plays a repetitive 24-hour news station. Opposite the TV is the nursing station – a wall lined with windows and a locked door.
There is a woman sitting cross-legged underneath the TV. She stares at her phone, and a charger is plugged into a wall outlet beside her.
You grab yourself a seat and give the wall a good stare.
As you fixate on the wall, or nothing in particular, your mind wanders. You try to piece together what is happening and why you came in. The further back you reach into your mind, the harder it is to recall.
Things aren’t that bad, afterall, are they? Wouldn’t it be nice to go home and take a nap?
You long for the doors to be opened so that you can be free. However, you know from experience that they won’t let you leave until you’ve seen a doctor.
Each memory you discover gets lost in the moment, except for the times when you get lost in the memory. You start to wish you had a pen and some paper to write this down, because your recall won’t likely improve by the time you see a doctor.
You have no idea why this is triggering your anxiety. You want to leave. You want to stay. You’re not sure what you’ll say.
Perhaps a nurse has some paper and a pen.
You’ve been in the ER for almost an hour. You hope they haven’t forgotten you.
The TV blares as usual. You think you’ve watched the news cycle repeat at least 5 times so far. You wonder if you can change the channel, but you don’t feel motivated to ask.
You sit down in one of the chairs and pick up one of the newspapers. It’s the free periodical they give out to commuters. You flip through a few pages trying to find something of interest to you.
You try to read, but your mind is too foggy to concentrate. The words melt off the page. You’re better off staring at a wall – it’s way harder to screw that up.
You’ve been in the ER for 2 hours. The boredom and frustration is building, but for the most part you manage to ignore it.
You have fully tuned out the TV. It’s just background noise now. You start to wish you had a handheld video game to play with. You wish you had something that could occupy your mind.
You look through the window in the nursing station. Around 8 people are inside, and they appear to be having a conversation amongst themselves. One of the male nurses laughs as he talks, though you cannot hear what he is laughing about.
How will you get their attention?
You gently knock on the door. You look inside – none of the nurses looked up. It seems that they haven’t even noticed.
You knock again, slightly harder. Still nothing.
You look through the window in the nursing station. Around 8 people are inside, and they appear to be having a conversation amongst themselves. One of the male nurses laughs as he talks, though you cannot hear what he is laughing about.
How will you get their attention?
You slam your fist on the window once.
“What are you doing?!”
A woman with long, dark hair looks up for a moment. She rolls her eyes and stands up. She approaches the door and opens it.
“How can I help you?” she asks, with a superficial cheeriness.
You try to explain, “I am really, really anxious. I’ve been waiting for a long time and I just thought if I could have–”
“We can’t give you Ativan. You have to wait for the doctor to order it for you.”
You shake your head. “I don’t want an Ativan. Can you please listen?”
While you’re talking, the nurse walks back inside and slams the door. You consider slamming your fists and screaming again, but it doesn’t seem like it would help.
A nurse approaches you and tells you that the psychiatrist will see you now. You breathe a sigh of relief and prepare to speak with him.
You follow the nurse to one of the side rooms with an open door and a table in the centre. There are two chairs. You step inside.
“Have a seat. Doctor Marion will be with you shortly.”
Wordlessly, you lower yourself into one of the chairs. You try to shift it gently towards the table, but the chair is quite heavy – perhaps deliberately weighed down. The armrests have no gap between the arm and the seat of that chair. You shrug your shoulders.
A young woman enters the room. Dr. Marion, you presume.
“Hello there, Jessica. I’m Dr. Marion, the resident psychiatrist. I hear you’re not having the best day.”
You nod.
“Tell me a little bit about what brings you in here.”
You respond, “I’m … it’s very hard to say.”
You break eye-contact because connection is too much. You’d rather dissociate yourself away from the situation than face it head-on.
Dr. Marion nods patiently. “Take your time. It’s all right.”
This is your final chance to leave. You can say whatever you want. Once the secret is out, you’ll likely be admitted as an involuntary patient. But if you say too little, you may be denied any help or support at all.
You take a deep breath.
With your eyes fixed on the floor, you try to summon the courage to say something. You are acutely aware of the power the psychiatrist has over you, and the next words you say could get you detained.
It isn’t that you honestly want that. You just don’t know what else to do. And yet at the same time, the part of you that wants to die is fighting the urge to say it.
You force it out. “I… I want to kill myself.”
She nods again. “OK. You want to kill yourself. How long have you felt this way?” Her nonchalant approach would normally seem quite odd, but nothing is normal about this conversation.
It feels like forever, but you know that isn’t true. “A few weeks,” you respond.
“All right. This is very important, so I’m going to ask you a few questions about it.”
Dr. Marion asks, “Why do you want to die?”

You take a deep breath. “I just don’t see another way. Life hurts so much, all the time, and I can’t handle it anymore.”

She responds, “Are there specifics? What makes your life this painful?”

You struggle to find words. Your heart races, and you are overtaken by a heavy shame. As the feeling settles in, you close your arms into your belly and look to the ground.

Dr. Marion says, “I know this is hard to talk about. Take your time.”

You nod slowly. It feels as though your larynx is swelling. You don’t want to say it. You don’t even want to think it.
Dr. Marion asks, “Why do you want to die?”
You take a deep breath. “I just don’t see another way. Life hurts so much, all the time, and I can’t handle it anymore.”
She responds, “Are there specifics? What makes your life this painful?”
You struggle to find words. Your heart races, and you are overtaken by a heavy shame. As the feeling settles in, you close your arms into your belly and look to the ground.
Dr. Marion says, “I know this is hard to talk about. Take your time.”
You nod slowly. It feels as though your larynx is swelling. You don’t want to say it. You don’t even want to think it.
It seems easier to talk around it than to actually talk about it, and if you get the same result – a safe place to rest for a few days – then there is no real upside to talking about it.
“It’s just hard. It’s so hard. I hate myself, and I want it to be over, and I don’t see any reason to go on.”
Dr. Marion nods. “I can see that you’re in a lot of pain. Is there more you can say about that?”
You can’t bear to look at her. “Cassandra was sick. I didn’t take her to the vet in time. She died, and it’s all my fault. I hate myself.”
Dr. Marion nods. “These things can happen, Jessica.”
“You don’t understand. She died because of me. She was the only thing keeping me going, and she died because of me.” You’re shaking now and finding it hard to focus.
“It sounds like you really cared about Cassandra. Pets are like family.”
“You don’t understand,” you say with a trembling voice. “She was the only reason I woke up in the morning. The only reason I didn’t kill myself was because she would end up at a shelter. Now that she’s gone I… I just don’t care anymore.”
“What about the rest of your family?” she asks.
You shake your head. All you can think to say is that they’ll be better off without you. You’ve made enough dramatics for now. You shake your head again, and again.
“Are you close to your parents? Siblings?”
“They will be better off without me,” you retort.
Dr. Marion jots a few things down and then looks at you again. “Do you have any plans to kill yourself?”
You nod, and she asks what it is. You take a deep breath and slowly explain the plan you had. You already own what you need, and you already wrote a note to your loved ones. The only thing left was to go home and do it.
“I think I know what we need to do right now. The most important thing, I think, is to keep you safe tonight.”
Dr. Marion frowns and looks at you sympathetically. “All right. Do you know what a Form 1 is?”
Of course you know what a Form 1 is. You’ve been formed so many times in the past that you couldn’t not know.
She continues, “A Form 1 is a 72-hour psychiatric evaluation. I’m concerned about you, and I think this is the best way to keep you safe. We can work on safety planning and medication while you’re here, and remember that it’s just 72 hours. Not forever.”
Dr. Marion says, “Your nurse will be with you shortly.” She leaves the room. You allow your mind to drift. Being formed used to be a novelty. You remember the first time. You were so terrified of what would happen to you. You were afraid you would never leave the hospital again. Yet, as time moved on with more life and experience, you came to realize that 72 hours was nothing. A couple sleeps, and you’ll head home.
You rest your back against the chair and wait for your nurse. A half-hour rolls by as you stare at the wall. Knowing that you’re somewhere safe for the night brings you a small amount of relief – confusing relief to be honest, as you still want to kill yourself. On some level it is nice to know that people will make sure you stay alive.
The security guard you met earlier walks in holding your backpack and purse. “I need to search and catalogue your belongings. When we’re done, they will stay behind the nursing station to ensure that you’re safe.”
You nod. He puts on two latex gloves and begins rummaging through your belongings. As he removes each clothing item he makes a small note of it on a piece of paper. Underwear here, bra there. He picks out a pair of pyjama pants and puts it in a separate pile. “You can’t have anything with a drawstring,” he says.
He takes your smartphone and charger, and puts it in a small plastic bag. You suppress a laugh when you notice the biohazard symbol on it.
“The laces from your shoes, please.”
The laces? You sigh and proceed to delace your shoes.
“Are you wearing a belt?” he asks.
You nod, and hand the belt over to him too. Your pants are barely clinging to your waist as you use your hands to hold them up.
“OK miss, one last thing.”
Another man who you didn’t see approaches you with a handheld metal detector. “Stand with your arms out,” he orders.
You consider your options.
You nod slowly. You don’t like being ordered around, but snapping at him won’t help.
This entire process always gets you. Supposedly it’s for your own safety, but you don’t normally care in the moment. You turn your eyes and head down to the floor, stretch your arms out, and let him proceed.
You close your eyes as the metal detector passes over your legs and arms. You always hate this part – always. It can’t be over soon enough.
A young white woman walks out of the nursing station and approaches you. “Hi Jessica, I’m Chanelle. I’ll be your nurse until 11:00.”
“Hi Chanelle,” you say while taking one quick glance at her face before watching the floor beneath you again.
She begins walking and you follow her footsteps. “Is this your first time in hospital?” she asks as you approach a pair of locked doors.
You shake your head. “First time at this one,” you say.
“OK. Hopefully here it’s not too different,” she says, seemingly without regard for your past experiences.
She holds her employee ID up to a card reader. It beeps, and she opens the door, holding it for you. You walk ahead of her, and the door slams shut.
“You won’t be down here for too long,” she says. “This is our crisis ER. We’ll try to transfer you soon, but for now you can stay down here.”
The walls are all coated in a dull white paint. As you’re walking you see some doodles and pencil marks on the wall. You follow Chanelle through a simple hallway. You glance into an open room while walking by. There are a few rows of tables, and a few soft chairs. The soft chairs are directed at a television. The TV sits behind a locked glass panel, and it’s currently turned off.
She stops at a door on the other end of the hallway and gestures for you to walk in. You do so. There is a small bed in this room.
You gently lower yourself on to the bed, and you fold your hands together. You fix your eyes on the floor in front of her feet.
Chanelle starts. “I just want to welcome you to the Crisis ER. Here we see patients who are in acute crisis. The first step is stabilizing your crisis. Dr. Marion gave me a quick overview but I always like hearing things directly from the patient.”
“I…” – you pause, you stutter. It has barely sunk in that this is really happening, and yet you’re being asked to tell your story again. You wonder why she can’t just read the notes. “I’m tired,” you say.
“Can you say more about that?” she responds.
You take a deep breath before responding. “My cat is dead. I’m locked in this prison for the next three days. I hate myself. I hate everything about myself, and I don’t see the point of living.”
Chanelle nods. “Right. So you’re having thoughts of suicide?”
“Yes,” you respond quietly.
“Do you have a plan for how you would do it?” she asks.
You find it difficult to explain again – you have forgotten by now how many people asked you this question. Your set your eyes onto the tiled floor as you explain your detailed plan. It takes about a minute to go over the usual “where, when, how” questions. You’re grateful when it’s over.
“That sounds like a really serious plan. How do you think your family would react if you did this?”
Family? You shrug your shoulders. “I figure they’re better off without me.”
“Do you think you’ll try to hurt yourself inside the hospital?”
You think for a moment about how you might accomplish this – you come up with a few creative, plausible solutions. But, would you? You think for a moment more and respond, “No, I don’t think so. Not with everyone watching me.”
Chanelle nods. “I’m very glad you came in. It sounds like you’re dealing with a lot right now. Dr. Marion ordered some Ativan for you. Just come get me if you need any.”
With that, she walks out of the room. You wonder if she found you abrasive. She did leave relatively quickly, but your overall impression is that she’s a kind
In particular, what did you think of the patient’s interactions with the nursing staff?

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1.A nurse is reinforcing with a client who has oral candidiasis and is to begin therapy with nystatin oral suspension. The nurse should tell the client to take which of the following actions? 1. Gargle with a commercial mouthwash before administering the medication. 2. Scrape off white patches on the tongue using a swab prior to medication administration. 3. Retain the medication in the mouth before swallowing. 4. Take the medication 1 hr before meals. 2.A nurse is caring for a client who has arthritis and reports he does not exercise because it is too painful. Which of the following actions should the nurse suggest? 1. Repeat the same number of exercises regardless of pain level. 2. Exercising in water will help with pain. 3. Think of something pleasant while exercising to reduce pain. 4. Soak affected joints in water that is 48.9 degrees( 120 degrees Fahrenheit) to ease pain. 3.A nurse is reinforcing teaching with a female client who has a history of urinary tract infections. Which of the following instructions should the nurse include? 1. Urinate before and after sexual intercourse. 2. Increase milk consumption to make the urine more alkaline. 3. Empty the bladder at least every 6 hr. 4. A nurse is caring for a client who has undergone hemodialysis. Which of the following findings should the nurse report to the provider? 1. Vibration at fistula site 2. Decrease in weight 3. Headache 4. Fatigue 5. A nurse working in a provider’s office is caring for a client who received penicillin 15 min ago to treat strep throat. Which of the following is the priority finding the nurse should report to the provider? 1. Hypertension 2. Nausea 3. Arthralgia 4. Abdomen pain 6. A nurse is caring for a client who is 1 day postoperative following an appendectomy. Which of the following should the nurse report? 1. Serosanguineous drainage at the incision site 2. Hypoactive bowel sounds in all four quadrants 3. Temperature 37.2 degrees(99 degrees Fahrenheit) 4. Red streaks along the incision 7. A nurse is caring for a client who has a prescription for a cerebrahanglogram. Which of the following actions should the nurse take? 1. Maintain the client NPO for 2 to 3 hr. 2. Instruct the client to limit activity for 48 hr following the procedure. 3. Inform the client she will receive sedation to prevent claustrophobia. 4. Determine if the client has an allergy to shellfish. 8. A nurse is caring for an older adult client immediately following a bronchoscopy with biopsy. Which of the following is the priority actions the nurse should take? 1. Instruct the client to gargle with warm saline. 2. Check for a gag reflex. 3. Document sputum color and consistency. 4. Differ ice chips 9. A nurse is reinforcing teaching with a client about increasing her intake of fiber. Which of the following foods should the nurse encourage the client to eat? 1. Fears 2. Cheese 3. Eggs 4. Yogurt 10. A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take? 1. Check the cuff pressure. 2. Increase the humidification. 3. Perform suctioning. 4. Instill saline into the tubing. 11. A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following statements by the client indicates an understanding of the teaching? 1. ´´I will use a skin sealant before I apply the bag.´´ 2. ´´I will cut the wafer opening one-fourth of an inch larger than the stoma.´´ 3. ´´I will use moisturizing soap to clean around the stoma before applying the bag.´´ 4. ´´I will need to empty the bag every 4 to 6 hours.´´ 13. A nurse is monitoring a client who is undergoing a blood transfusion of packed RBCs. The nurse should recognize that which of the following findings indicates fluid overload? 1. Bradycardia 2. Pruritus 3. Fever 4. Dyspnea 14. A nurse is caring for a client who has a new prescription for nitroglycerin. The nurse should monitor for which of the following adverse effects of the medication? 1. Fever 2. Nocturia 3. Flushing 4. Increased saliva production 15. A nurse is collecting data from a client who is taking metoprolol. Which of the following findings should the nurse expect? 1. Decreased heart rate 2. Increased blood glucose level 3. Increased blood pressure 4. Decreased bronchospasms 16. A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease. Which of the following dietary instructions should the nurse include? 1. Drink carbonated beverages with meals. 2. Use a straw when drinking liquids. 3. Limit meals to three per day with no snacking in between. 4. Chew food thoroughly. 17. A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching? 1. ´´My risk for a stroke increases if my HDA1c level is 6 percent or less.´´ 2. ´´Having a total cholesterol level below 200 mg/dL increases my risk for a stroke.´´ 3. ´´My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke.´´ 4. ´´I can decrease my risk for a stroke by losing excess weight.´´ 18. A nurse is reinforcing teaching with a client who has celiac disease. Which of the following statements by the client indicates an understanding of the teaching? 1.´´I eat rice cakes instead of toast.´´ 2. ´´I no longer eat corn or nuts.´´ 3. ´´I cook soups with barley instead of egg noodles.´´ 4. ´´Í have switched to non dairy coffee creamer.´´ 19. A nurse is caring for a client who has a closed head injury. In which of the following positions should the nurse place the client? 1. Semi-Fowler´s 2. Sims’ 3. Modified Trendelenburg 4. Prone 20. A nurse is assisting in teaching a group of nurses about pain management for older clients. Which of the following information should the nurse include in the teaching? 1. Reassess the effectiveness of the pain relief measures every 3 hr. 2. Use nonpharmacological measures as a substitute for pain medication. 3. Recognize that a cognitive impaired older adult client can identify the intensity of pain. 4. Withhold pain medication until the client reports a pain level of 6 or higher on a scale from 0 to 10. 21. A nurse is preparing to enter the room of a client who has tuberculosis. Which of the following personal protective equipment should the nurse wear? 1. Surgical mask 2. Nonrebreather mask 3. Respirator mask 4. Venturi mask 22. A nurse is caring for a client who is postoperative following a right total knee arthroplasty. Which of the following actions should the nurse take ? 1. Apply the CPM device over the knee immobilizer. 2. Elevate the head of the bed 30 degrees before starting the CPM device. 3. Ensure the knee joint is positioned over the CPM device frame joint. 4. Ensure the hip is in full abduction when applying the CPM device. 23. A nurse is caring for a client who is receiving an IV bolus and whose site has infiltrated, identify the sequence in which the nurse should remove the IV catheter. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1. Clamp the IV tubing. 2. Hold the client’s arm above the level of the heart. 3. Remove the dressing and tape from the venipuncture site. 4. Withdraw the catheter from the client’s vein 24. A nurse is caring for a client who has stomatitis due to chemotherapy. Which of the following is an appropriate food choice for the nurse to offer? 1. Milk shake 2. Fresh fruit 3. Tomato soup 4. Dry toast 25. A nurse is reinforcing teaching about foods containing potassium with a client who has a new prescription for hydrochlorothiazide. Which of the following foods should the nurse recommend as the best source of potassium? 1. ½ cup cucumber slices 2. ½ cup okra 3. 1 cup apricot slices 4. 1 cup pineapple chunks 26. A nurse is reviewing the ABG value of a client who has pneumonia. Which of the following indicates the client is developing respiratory acidosis? 1. Pa02 85 mm Hg 2. pH 7.47 3. HC02 25 mm Hg 4. PaCO2 55 mm Hg 27. A nurse is assisting with the administration assessment of a client who has late-stage emphysema. The nurse should recognize which of the following as an expected finding? 1. Chubbing of the fingernails 2. Elevated body mass index 3. Slow, deep respiration 4. Flushed facial skin 29. A nurse is reinforcing dietary teaching with a client who has neutropenia. Which of the following foods should the nurse encourage the client to consume? 1. Fresh fruit 2. Broiled chicken 3. Raw vegetables 4. Soft-boiled eggs 30. A nurse is reinforcing teaching with a client who is prescribed levothyroxine for a thyroid disorder. Which of the following information should the nurse include in the teaching? 1. Take the medication with an aluminum-containing antacid. 2. Expect to discontinue the medication after 1 month. 3. Notify the provider if resting pulse is less than 80/min. 4. Administer the medication 1 hr before breakfast. 31. A nurse is reinforcing discharge teaching with a client who had an abdominal hysterectomy 2 days ago. Which of the following instructions should the nurse include in the teaching? 1. ´´Expect bright red vaginal bleeding for 1 week following surgery.´´ 2. Douche with warm water to remove vaginal discharge.´´ 3. ´´Avoid climbing stairs for 8 weeks.´´ 4. ´´Take a shower rather than a tub bath.´´ 32. A nurse is caring for a client who has deep-vein thrombosis. Which of the following interventions should the nurse plan to take? 1. Place the client’s bed in reverse Trendelenburg position. 2. Measure the calf of the affected extremity each shift. 3. Massage the affected extremity every 4 hr. 4. Apply cold compresses to the affected extremity. 33. A nurse is caring for a client who has diabetes mellitus. Which of the following laboratory findings indicates the client has maintained control of his blood glucose levels for the past 3 months? 1. Fasting blood glucose 100 mg/dL 2. HbA1c 12.5% 3. Fasting blood glucose 70 mg/dL 4. HbA1c 6.5% 34. A nurse is monitoring a client who is receiving intravenous fluids. Which of the following findings indicates a fluid volume excess? SATA 1. Hypertension 2. Flat neck veins 3. Weight gain 4. Bradycardia 5. Dyspnea 35. A nurse is reinforcing teaching about ways to promote health with an older adult client. Which of the following statements by the client indicates the teaching was effective? 1. ´´I will limit my dietary fat to 40% of my total calories.´´ 2. ´´I will exercise for 30 minutes five times per week.´´ 3. ´´I will socialize with my friends on a regular basis.´´ 4. ´´I will apply sunscreen on cloudy days when going outside.´´ 5. ´´I will get an influenza vaccination every 2 years.´´ 36. A nurse is reinforcing teaching with a client who is being discharged following a prostatectomy. Which of the following statements should the nurse include in the teaching? 1. ´´You might see blood in your urine after coughing.´´ 2. ´´You may take aspirin for mild pain.´´ 3. ´´You should shower instead of taking a tub bath.´´ 4. ´´You may resume sexual intercourse after 2 weeks.´´ 5. ´´You should avoid lifting objects that weigh more than 8 pounds.´´ 37. A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer’s disease. Which of the following actions should the nurse take? 1. Participate in reminiscence therapy with the client. 2. Alternate the client´s daily routine. 3. Keep the lights dimmed. 4. Raise the four side rails on the client’s bed. 38. A nurse is contributing to the plan of care for a client who has disuse syndrome following cast removal from a lower extremity. Which of the following referrals should the nurse include in the plan of care? 1. Social worker 2. Dietitian 3. Occupational therapist 4. Herbalist 39. A nurse is caring for a client who has hypocalcemia. For which of the following findings should the nurse monitor? 1. Decreased bowel sounds 2. Increased blood pressure 3. Tetany 4. Lethargy 40. A nurse is reinforcing health promotion education at a community health fair. Which of the following statements by attendees indicates understanding of the teaching? 1. ´´I will examine my breasts a week after each menstrual period.´´ 2. ´´I should get a hepatitis B vaccine on a yearly basis.´´ 3. ´´I do my testicular self-exam every 6 months without fail´´ 4. ´´The flu shot I received last year will last me for 2 years.´´ 41. A nurse is reinforcing urinary bladder training for a client who has urge incontinence. Which of the following instructions should the nurse include? 1. Drink citrus juice with breakfast. 2. Keep a voiding diary for 3 days. 3. Void as soon as the urge occurs. 4. Restrict fluids to meal time. 42. A nurse is reinforcing teaching about a heart-healthy diet with a client. Which of the following statements by the client indicates that the teaching was effective? 1. ´´I will eat chicken as my source of fiber.´´ 2. ´´I will increase my intake of lean red meat.´´ 3. ´´I will increase my servings of canned vegetables.´´ 4. ´´I will use skim milk as my source of diary.´´ 43. A nurse is reinforcing teaching about the use of an insulin pen with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? 1. ´´I will hold the pen upside-down to select the appropriate dose.´´ 2. ´´I will shake the pen before injecting the insulin.´´ 3. ´´I will aspirate before injecting the insulin.´´ 4. ´´I will apply a disposable needle on the cartridge.´´ 44. A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include? 1. Restrict the diet to clear liquids for 1 to 3 days before the procedure. 2. Administer enemas 2 days before the procedure. 3. Do not eat or drink anything except water for 12 hr before the procedure. 4. Expect the provider to schedule another procedure to remove any polyps. 45. A nurse in a provider’s office is reviewing the medical record of a client. Based on the information provided in the medical record, which of the following findings places the client at risk for breast cancer? 1. BRCA1 result 2. Obstetric history 3. Biopsy result 4. Race 46. A nurse is prioritizing care for four clients following change-of-shift report. Which of the following clients should the nurse attend to first? 1. A client who has Alzheimer’s disease and requires assistance to the bathroom 2. A client who has diverticulitis and a temperature of 38.3 degrees( 100.9 degrees Fahrenheit). 3. A client who has a prescription for a sputum specimen to be obtained before breakfast. 4. A client who sustained a head injury 2 days ago and has a decreased level of consciousness. 47. A nurse is assisting with the admission of a client who has multiple sclerosis. Which of the following sections is the priority for the nurse to take? 1. Determine the client’s ability to see the buttons on the call light. 2. Encourage the client to verbalize her feelings. 3. Discuss the possible changes in family roles. 4. Assist the client and family locating a community support group. 48. A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take? 1. Raise all four side rails while the client is in bed. 2. Move the overbed table away from the bed. 3. Leave the television on in the client’s room. 4. Apply a motion sensor mat to the client’s bed. 49. A nurse is reinforcing teaching about meal planning with a client who has hypertension. Which of the following statements by the client indicates an understanding of the teaching? 1. ´´I can have a bologna sandwich.´´ 2. ´´I can have canned soup.´´ 3. ´´I can season food with ketchup.´´ 4. ´´I can season food with vinegar.´´ 50. A nurse is transporting a client who has pneumonia and is on droplet precautions to radiology. Which of the following safety measures should the nurse take while transporting the client? 1. The client should wear a gown during transport. 2. The nurse should wear a gown during transport. 3. The client should wear a mask during transport. 4. The nurse should wear a mask during transport.

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Question 11 pts
The client tells you he takes aspirin every day. What question should be asked next?
Group of answer choices
“Does the drug upset your stomach?”
“Was this prescribed by your provider?”
“Have you had any prolonged bleeding or bruising?”
“Why are you taking aspirin daily?”
Flag question: Question 2Question 21 pts
You realize that as an Advanced Practice Nurse you must ask questions regarding sensitive topics. To be most effective you employ the basic principles that guide responses to sensitive topics. The most important rule is:
Group of answer choices
Be nonjudgmental
Be focused
Be direct
Be succinct
Flag question: Question 3Question 31 pts
Cultural competence is best enhanced when the health care provider:
Group of answer choices
Uses self-awareness and reflection.
Relies on group stereotypes
Personally values health
Uses a single-focus approach
Flag question: Question 4Question 41 pts
You are assessing Jenna’s broken arm in the ER and you suspect she may be a victim of violence. What statement triggered your concern?
Group of answer choices
“Can you call my boyfriend?”
“It really hurts.”
“I was in the ER last month for a cold.”
“I hurt it about 4 days ago.”
Flag question: Question 5Question 51 pts
You are going to organize a BP screening fair at the mall. You are involved in
Group of answer choices
Early prevention
Tertiary prevention.
Primary prevention
Secondary prevention
Flag question: Question 6Question 61 pts
Your patient presents with left elbow pain, as you document his HPI you note his c/o swelling.
In your symptom analysis this would be considered:
Group of answer choices
Radiation
Associated symptom
Quality
Severity
Flag question: Question 7Question 71 pts
Your patients daughter is explaining to you why her mother, who has dementia is here. Her mother is not able to articulate the answer. This is an example of…
Group of answer choices
chief complaint
Family History
Objective information
subjective information
Flag question: Question 8Question 81 pts
Mr. Bill presents to your office for a physical. You note that his BMI is 27. You inform him that this is considered…
Group of answer choices
Borderline
Normal for his height
Obesity
Overweight
Flag question: Question 9Question 91 pts
A 44 year old man who admits to drinking “a few beers now and then” presents for examination. After obtaining an excellent health history and performing a physical examination. you suspect he is a heavy drinker. Your next action is to:
Group of answer choices
confront the patient with your observation
obtain liver enzymes
administer the CAGE questionnaire
You need to explain that looks like something he will need to work on in the future
Flag question: Question 10Question 101 pts
You are meeting for the first time a 14 yr old female patient. You would want to include the following in your exam.
Group of answer choices
TSH & T4
HCG & GC
HEADS & RAFFT
CBC & PPD
Flag question: Question 11Question 111 pts
As the NP you have given your patient the mini-mental exam. The patient scored 11. Given that the maximum score is 30, What does this score tell you?
Group of answer choices
The patient has severe cognitive impairment
The patient is depressed
The patient is uneducated
The patient has moderate cognitive impairment
Flag question: Question 12Question 121 pts
Which of the following is NOT one of the components of the adult health history?
Group of answer choices
Identifying data
History of present illness
Physical examination
Review of systems
Flag question: Question 13Question 131 pts
Mr. Sherman is a 45 yr. old accountant who presents to your office for an annual routine exam. He reports that he is a smoker (22Pk Yr. Hx). He states that he drinks 4 to 6 cans of beer a day, which he finds helps him to wind down after work. He denies any allergies. He denies any medications. His family history is positive for heart disease. His major leisure activity is watching television. He rarely exercises, but occasionally plays softball on the weekend. He is recently divorced and lives alone in a studio apartment. He has no children. On physical exam you find that his height is 66 in., weight 90 kg (198 lbs), and BP 148/90.

What health problems does Mr. S. present with?
Group of answer choices
Alcohol abuse, depression related to recent divorce, high-fat diet, obesity, hypertension, lives alone, overnutrition, muscle atrophy
Alcohol abuse, exercise intolerance, inactivity, hypertension, obesity, lives alone, recent divorce, social isolation.
Tobacco abuse, obesity, depression, exercise intolerance
Tobacco abuse, alcohol abuse, stress associated with work & recent divorce, inactivity, family history of heart disease, obesity, elevated blood pressure.
Flag question: Question 14Question 141 pts
Mr. Sherman is a 45 yr. old accountant who presents to your office for an annual routine exam. He reports that he is a smoker (22Pk Yr. Hx). He states that he drinks 4 to 6 cans of beer a day, which he finds helps him to wind down after work. He denies any allergies. He denies any medications. His family history is positive for heart disease. His major leisure activity is watching television. He rarely exercises, but occasionally plays softball on the weekend. He is recently divorced and lives alone in a studio apartment. He has no children. On physical exam you find that his height is 66 in., weight 90 kg, and BP 148/90.
Which of the following is not true regarding Mr. Sherman’s weight?
Group of answer choices
He’s at risk for obstructive sleep apnea
He’s not at increased risk; his weight is WNL (within normal limits)
He’s may be self treating depression with food.
He’s at risk for CAD
Flag question: Question 15Question 151 pts
Mr. Sherman is a 45 yr. old accountant who presents to your office for an annual routine exam. He reports that he is a smoker (22Pk Yr. Hx). He states that he drinks 4 to 6 cans of beer a day, which he finds helps him to wind down after work. He denies any allergies. He denies any medications. His family history is positive for heart disease. His major leisure activity is watching television. He rarely exercises, but occasionally plays softball on the weekend. He is recently divorced and lives alone in a studio apartment. He has no children. On physical exam you find that his height is 66 in., weight 90 kg, and BP 148/90.
What risk factors for coronary artery disease does Mr. S. have at this time?
Group of answer choices
Smoking, alcohol abuse, family history, lives alone.
Family history, alcohol abuse, depression.
Family history, obesity, hypertension
Smoking, elevated blood pressure, family history, obesity, age 45.
Flag question: Question 16Question 161 pts
Mr. Jones is a new patient and newly diagnosed diabetic. You realize that in order to get reimbursed at a higher level for the diabetic education you have done, you must document the time spent on this education at least what percentage of the visit.
Group of answer choices
more than 50% of visit
at least 25% of visit
at least 75% of visit
more than 85% of visit
Flag question: Question 17Question 171 pts
Susie Lee (25) presents for a checkup to your office. You have not seen her before. She was last seen by the MD in your group for a URI (upper respiratory infection) 4 years ago. Todays visit would be considered_________ according to the CPT definition.
Group of answer choices
an established patient
concurrent care
a new patient
billable at a higher level
Flag question: Question 18Question 181 pts
Your patient is seen for “ankle pain” . In your note you document that he c/o pain in the left lateral ankle radiating to the back of the heel. Pain is a 6 (1-10 scale), and worse when he puts pressure on it. He denies swelling, bleeding or bruising. He’s taken Advil 400mg twice, which helped minimally. In order to have a complete HPI for your CPT code, what is missing?
Group of answer choices
Any family members with osteoarthritis?
What meds is he on?
When did it begin?
What does he think it is?
Flag question: Question 19Question 191 pts
The keys to select the right level for billing include:
Group of answer choices
History, counseling, time
History, exam, decision making
Time, coordination of care, exam
Exam, decision making, time
Flag question: Question 20Question 201 pts
When performing a history & physical on a pediatric patient, which important factor affect the outcome the most:
Group of answer choices
child’s health
child’s fears
child’s verbal ability
child’s development level
Flag question: Question 21Question 211 pts
In medical billing the abbreviation CPT stands for:
Group of answer choices
Current Procedural Terminology
Compendium of Procedures and Therapies
Current Pricing Tier
Clinical Practice Terminology
Flag question: Question 22Question 221 pts
When obtaining a health history from an older client, which characteristics of the older client must be taken into consideration?
Group of answer choices
The older client requires a lot of repetition because the IQ declines with the aging process.
Auditory acuity is the most common sensory loss in the aged population and may hinder the interview.
An older client’s response time to answering a question is just as quick as that of a young client.
The older client responds to pain sensation with the same intensity as a young client.
Flag question: Question 23Question 231 pts
Mr. Williams is a new patient and has no complaints, but wants a physical. His physical exam is unremarkable but some of the findings from his history are concerning. Of the following, which would NOT put him at risk ?
Group of answer choices
3 beers/day
BMI > 26
waist of 32 inches
loose fitting false teeth
Flag question: Question 24Question 241 pts
The most important question to ask as you build your HPI is:
Group of answer choices
Have you ever had this before?
Men, women, or both
What time did it start?
have you had nausea?
Flag question: Question 25Question 251 pts
As an APN you believe strongly in anticipatory guidance and prevention education. You explain that all of the following are steps to address smoking except:
Group of answer choices
advise
assist
assess
arrange
admit
Flag question: Question 26Question 261 pts
Limiting public smoking is an example of tertiary prevention
Group of answer choices
True
False
Flag question: Question 27Question 271 pts
James is a 17 yo old patient who presents for a school physical. You have set aside time for screening prevention. Based on the leading cause of mortality for this student what should you discuss..
Group of answer choices
depression
HIV risk
seat belt use
vaccination status
Flag question: Question 28Question 281 pts
Which of the following women should have screening for cervical cancer?
Group of answer choices
a 19 yo virgin
a 21 yo with one male partner
An 18 yo who has a history of genital warts
a sexually active 16 yo
Flag question: Question 29Question 291 pts
Larry 25yo male presents to have a TB test read. This visit should be billed at:
Group of answer choices
99213
99212
99211
99214
Flag question: Question 30Question 301 pts
Which of the following patients is least likely to become an alcohol abuser?
Group of answer choices
a 19 yo college student who binges on alcohol but only on the weekends
a 70 yo male who feels better after drinking rum in the morning
a 50yo construction worker who drinks 1 beer nightly while watching baseball on TV
a 30 yo nurse who complains that her mother’s comments about her recreational drinking are starting to annoy her and her spouse
Flag question: Question 31Question 311 pts
Ted, who is 15yo has just moved into the community and is staying in a foster home temporarily. There is no record of immunization. His foster mother wants him to be checked before he enters the local high school. Which of the following does he need?
Group of answer choices
All of the above
meningococcal
Tdap
Measles-Mumps-Rubella (MMR)
Flag question: Question 32Question 321 pts
A sedentary, obese 52 yo woman is diagnosed with HTN and states: “It is going to be hard to diet, exercise, and take these pills”. Which of the following responses is the least helpful?
Group of answer choices
“Could you start with reducing the amount of salty foods in your diet?”
“Tell me what you feel will get in your way of improving your health?”
“Perhaps you could try taking your medication when you brush your teeth”
“You really need to try and improve your health.”
Flag question: Question 33Question 331 pts
A NP is evaluating an 85yo male from a nursing home. The NP instructs the patient to remember the words orange, street, and tiger. The patient is instructed to repeat these words back to the NP in 10 minutes. Which of the tests is being described?
Group of answer choices
Minnesota Multphasic Personality Inventory (MMPI)
The CAGE test
Beck Inventory
Mini-Mental status exam
Flag question: Question 34Question 341 pts
In doing a cultural assessment on your patient all of the following are components of the assessment except:
Group of answer choices
What are the roles in the family?
What religious influences may affect care?
What is the patient’s income?
What are the patient’s personal belief about health?
Flag question: Question 35Question 351 pts
When caring for a patient with sensitive issues, which of the following is the most therapeutic approach?
Group of answer choices
Be vague so you don’t offend the patient.
Push to get the accurate and necessary answers
Offer the patient the opportunity to ask questions
Apologize for having to ask difficult questions
Flag question: Question 36Question 361 pts
The SCOFF screening tool is used to diagnose eating disorders.
Group of answer choices
True
False
Flag question: Question 37Question 371 pts
When researching the elderly population, what is the fastest growing age range?
Group of answer choices
81-84 years
85 and older
71-75 years
76-80 years
Flag question: Question 38Question 381 pts
Your patient is a 43 year old female in today for an annual physical exam. Her history is unremarkable, she has no new diagnosis or surgeries since seen last year and is otherwise health. When you begin questioning her about her cardiac ROS, she becomes tearful and states:” I just know Im going to have a heart ache some day.” Your best response would be:
Group of answer choices
If I were you, I would get an EKG and have a cardiac stress test – I can order those for you today.
Im sure you’ll be just fine, you don’t have a cardiac history.
You don’t need to worry about that, you’re young and healthy.
It sounds like this is a big concern of yours, can you tell me more about it?
Flag question: Question 39Question 391 pts
As a nurse practitioner, you have been asked to serve on a committee to assess the social determinants of health for a community. Of the following considerations, choose the one that is not a social determinant of health.
Group of answer choices
Ease of access to fresh food.
The prevalence of diabetes in a community.
Accessability for persons with disabilities.
Availability of safe recreational areas.
Flag question: Question 40Question 401 pts
When screening a patient for their risk of experiencing violence/domestic violence, there are 2 important questions to ask. Of the following, choose both appropriate questions:
Group of answer choices
Have you ever been hit by your partner?
Has your partner ever given you a sexually transmitted disease?
How many times have you been to the ER in the last year?
Have you been forced to have sex by your partner?

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Question
The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the patient’s input. The patient asks, “How is this different from what the doctor does?” Which response would be most appropriate for the nurse to make?__________________________________________________________
question.
Question
The nurse describes to a student nurse how to use evidence-based practice (EBP) when caring for patients. Which statement by the nurse accurately describes the use of EBP?
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The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which statement by the student nurse indicates that teaching was successful?
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Question
After administering medication, the nurse asks the patient if pain was relieved. What is the purpose of the evaluation phase of the nursing process?
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Question
The nurse admits a patient to the hospital and develops a plan of care. What components should the nurse include in the patient problem statement?
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Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/VN)?
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The nurse is caring for an older adult patient who needs continued nursing care and physical therapy to improve mobility after surgery to repair a fractured hip. The nurse would help to arrange for transfer of the patient to which facility? element is a more accessible alternative to drag & drop reordering. Press Enter or Space to move this question
.Question
The nurse works in a clinic located in a community where many of the residents are Hispanic. Which strategy, if implemented by the nurse, would decrease health care disparities and promote health equity for this community?
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Question
What information should the nurse collect when assessing the health status of a community?
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The nurse is caring for a patient who speaks a different language. If an interpreter is not available, which action by the nurse is appropriate? a more accessible alternative to drag & drop reordering. Press Enter or Space to move this question.
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Which action should the nurse include in the plan of care for a hospitalized patient who uses culturally based treatments? is a more accessible alternative to drag & drop reordering. Press Enter or Space to move this question.
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The nurse working in a clinic in a primarily black community notes a higher incidence of uncontrolled hypertension in the patients. To address this health disparity and promote health equity, which action should the nurse take first?
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During the health history interview, a patient tells the nurse about periodic fainting spells. Which question should the nurse ask to elicit any associated clinical manifestations?
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The nurse records the following general survey: “The patient is a 50-year-old Asian female accompanied by her husband and two daughters. Alert and oriented. Does not make eye contact with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or distinguishing features.” What additional information should the nurse add to this general survey?
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A nurse performs a health history and physical examination with a patient who has a right leg fracture. Which assessment would be a pertinent negative finding?
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The nurse asks an older adult patient with rectal bleeding, “Have you ever had a colonoscopy?” The nurse is performing what type of assessment?
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The nurse is preparing to perform a focused assessment for a patient reporting shortness of breath. Which equipment will be needed?
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Which adaptations to the physical examination technique should the nurse include for an alert older adult patient? element is a more accessible alternative to drag & drop reordering. Press Enter or Space to move this question.
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While the nurse is taking the health history, a patient states, “My mother and sister both had double mastectomies and were unable to exercise for weeks.” Which functional health pattern is represented by this patient’s statement?
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A patient has arrived at the hospital with severe abdominal pain and hypotension. Which type of assessment should the nurse do at this time? element is a more accessible alternative to drag & drop reordering. Press Enter or Space to move this question.
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The registered nurse (RN) cares for a patient who was admitted a few hours previously with back pain after a fall. Which action can the RN delegate to unlicensed assistive personnel (UAP)?
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Which physical assessment action should the nurse take after inspecting a patient’s abdomen?
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Question
An alert older patient who takes multiple medications for chronic cardiac and pulmonary diseases lives with a daughter who works during the day. During a clinic visit, the patient tells the nurse that she has a strained relationship with her daughter and does not enjoy being alone all day. In planning care for this patient, which problem should the nurse consider as the priority? element is a more accessible alternative to drag & drop reordering. Press Enter or Space to move this question.
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The nurse cares for an older adult patient who lives in a rural area. Which intervention should the nurse plan to implement to meet this patient’s needs? element is a more accessible alternative to drag & drop reordering. Press Enter or Space to move this question.
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A patient who has just relocated to a long-term care facility is exhibiting signs of stress related to the move. Which action should the nurse include in the plan of care?
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The nurse is admitting an acutely ill, older patient to the hospital. Which action should the nurse take?
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The nurse cares for an alert, homeless older adult patient who was admitted to the hospital with a chronic foot infection. Which intervention is the priority for the nurse to include in the discharge plan for this patient?
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The nurse will assess an older patient who takes diuretics and has a possible urinary tract infection (UTI). Which action should the nurse take first? element is a more accessible alternative to drag & drop reordering. Press Enter or Space to move this question.
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An adult patient who arrived at the triage desk in the emergency department (ED) with minor facial lacerations after a motor vehicle accident has a blood pressure (BP) of 182/94. Which action by the nurse is appropriate?
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An adult patient who is hospitalized after a motorcycle crash tells the nurse, “I didn’t sleep last night because I worried about missing work at my new job and losing my insurance coverage.” Which patient problem is appropriate to include in the plan of care?
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A patient is extremely anxious a few minutes before having a biopsy on a femoral lymph node. Which technique should the nurse recommend that the patient use during the procedure?
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A nurse prepares an adult patient with a severe burn injury for a dressing change. The nurse plans to try providing music to help the patient relax. Which action is best for the nurse to take?
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A patient reports difficulty falling asleep and daytime fatigue for the past 6 weeks. What is the best initial action for the nurse to take in determining whether this patient has chronic insomnia?
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A patient with chronic insomnia asks the nurse about ways to improve sleep quality. Which response by the nurse is accurate?
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What is the first action the nurse should take in addressing a patient’s concerns about insomnia and daytime fatigue?
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When caring for patients with sleep disorders, which activity can the nurse appropriately delegate to unlicensed assistive personnel (UAP)?
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Which assessment finding should alert the nurse to ask the patient about alcohol use?
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The nurse plans postoperative care for a patient who smokes 2 packs of cigarettes daily. Which goal should the nurse include in the plan of care for this patient?
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A patient admitted to the hospital after an automobile crash is alert and does not appear to be highly intoxicated. The blood alcohol concentration (BAC) is 110 mg/dL (0.11 %). Which action by the nurse is appropriate? element is a more accessible alternative to drag & drop reordering. Press Enter or Space to move this question.
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A patient with alcohol dependence is admitted to the hospital with back pain after a fall. Twenty-four hours after admission, the patient becomes tremulous and anxious. Which action by the nurse is appropriate?
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A patient with a history of heavy alcohol use is diagnosed with acute gastritis. Which statement by the patient indicates a willingness to stop alcohol use?
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A newly admitted patient reports waking frequently during the night. The nurse observes the patient wearing a nicotine patch on the right upper arm. Which action should the nurse take first?
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During physical assessment of a patient who has frequent nosebleeds, the nurse finds nasal sores and necrosis of the nasal septum. The nurse should ask the patient specifically about the use of which drug?
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A patient admitted with shortness of breath and chest pain who is a pack-a-day smoker tells the nurse, “I am just not ready to quit smoking yet.” Which response by the nurse is appropriate for the patient’s stage of change?
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A 73-yr-old patient is admitted with pancreatitis. Which tool would be the most appropriate for the nurse to use during the admission assessment?
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An older adult patient who has been taking alprazolam (Xanax) calls the clinic asking for a refill of the prescription 1 month before the alprazolam should need to be refilled. Which response by the nurse is best?
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The nurse cares for an agitated patient who was admitted to the emergency department after taking a hallucinogenic drug and trying to jump from a third-story window. Which patient problem should the nurse assign as the highest priority?
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A patient presents to the emergency department with a blood alcohol concentration (BAC) of 0.18%. After reviewing the prescribed medications, which drug should the nurse administer first?
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Which information is most important for the nurse to report to the health care provider about a patient who has been using varenicline (Chantix)?
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A patient who has a history of ongoing opioid use is hospitalized for surgery. After a visit by a friend, the nurse finds that the patient is unresponsive with pinpoint pupils. Which prescribed medication should the nurse expect to administer?

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Student Name: 38C Grade: /100
REFLECTION (25 points)
During the stimulations, I felt a lot of anxiety. Even though this was a preparation for the real world, I felt like I was in an urgent situation and had to act quickly, which increased my heart rate. After the first time through, I learned to do what was essential, then do everything else. However, I am still trying to understand what is the most important because in every situation, the assessment will change per patient. I learned to address the issue at hand and do reviews directly related to the needed interventions. I do not think I should have a timeline for achieving patient assessments. I am still learning health diagnoses and signs/symptoms as a student. The stimulations help me to know basic ways to address different diagnoses. I like that we play three different roles, being the students, the instructors, and the patients. Those roles give an insight into what to expect when out at practice sites. However, I had a lot to learn before I felt confident going into any patient room and addressing their issue. Even so, I think that the stimulation orientation should be divided into two sections to get a comfortable and formidability of the assessment and help reduce anxiety. Otherwise, I will not change anything.
GENERAL INFORMATION (30 points)
Primary Medical Diagnosis
15 points
Provide a detailed description of the primary medical diagnosis that will be used for this assignment. Include all symptoms, treatments, risk factors, medications, therapies, labs, and diet.
In general, multiple sclerosis is an autoimmune disease in which the immune system fights the protective layer covering the nerves. This may result to nerve damage, hence hinder connection between the body and the brain. This condition cannot be cured, but treatment can reduce the severity of the symptoms.
The symptoms are severe, and duration can vary from one person to another. In diagnosis, imaging and lab tests are required. Treatment for this condition involves many drugs, therapy, and general management.
References: Dobson, R., & Govannoni, G. (2019). Multiple sclerosis. European journal of neurology.
Potential Secondary Medical Complications
5 points
Identify two potential medical complications associated with the primary medical diagnosis. Explain why each is a potential complication.
NOTE: These are NOT nursing diagnoses.
1
Bladder and bowel problems like incontinence, constipation, or diarrhea. This occurs due to interruption of the communication between the brain and the bowel or urinary tract.
2
Nerve damage affects transmission of signals; hence the body cannot receive information to release waste products
Vision problems like blurred vision, double vision, nystagmus, or total vision loss. This occurs due to the damage of the nerve supply to the eye.
References: Amarenco, G., Bosco, S., & Boiteau, F., (2001) Urologic complications of multiple sclerosis.
Nursing Care
10 points
Describe in detail all the appropriate nursing care for the primary medical diagnosis.
NOTE: This is what you, as the nurse, will be doing to care for a patient with this diagnosis. For example: encourage, monitor, assess, teach, etc. Nursing care often does not require a provider order.
Since the patient has decreased energy production, as a nurse, I will advise the patient to take enough food to provide energy and have enough rest to avoid energy loss.
I will also provide the patient with the walking aids like walkers, wheelchairs, or braces since she has difficulty in walking and supporting herself.
Provide the patient with physical therapy, massage her and give relaxing bath to help maintain her skin integrity.
Advise her always to participate in groups involving fitness and exercise or to join multiple sclerosis societies.
Administer medications as indicated in the treatment sheet.
Encourage her to do self-care to her ability and assist her do the one she cannot do.
Allow her to do most of the activities during morning hours when the energy level is still high.
Encourage her to do stretching exercises and provide cold packs to help in proper alignment of the body.
Establish a therapeutic relationship with her to alleviate anxiety and feel valued.
Provide analgesics like tramadol, morphine, or pethidine to relieve pain and make her comfortable.
References: Halper, J & Holland, N., (2010). Comprehensive nursing care for multiple sclerosis. Springer Publishing Company.
PATIENT SPECIFIC INFORMATION (15 points)
Primary Medical Diagnosis Findings
10 points
List patient specific assessment information and findings directly related to the primary medical diagnosis. Include all symptoms, medications, treatments, therapies, labs, and diet.
Patient is alert and oriented x3 (person, place, time) vital signs as are followed, 02 sat is 96% on room air, R 18, T 98.5 F, B/P 124/76 patient 6 gaze is intact, right knee, and right elbow pain is 3/10 on the numeric pain scale. Bilateral legs numbness, tingling, and weakness. bruises to right knee and right elbow. Patient’s dorsiflexion and plantar flexion of bilateral feet equal but very weak. Patient last bowel movement was 1/26/2022. Diplopia (Double vision), severe pain, fatigue, impaired coordination, Patient report severe neck pain and generalized muscle spasm, pain rate of 9 on a scale from 0-10. Flexeril 10 mg up to three times a day as needed
Interferon beta- 1b (betaseron) 0.25 every other day subcutaneously
Patient starts IV line-will be used to administer methylprednisolone daily IV for 5 days
After completion of IV methylprednisolone, patient will be starting on oral prednisone to be tapered down and eventually stopped over the course of six days Add PRN med: Hydrocodone- acetaminophen (5-325) 1 tablet every four hours as needed for severe pain. Bilateral numbness. In the laboratory, the tests that helps in ruling out the disease from other differential diagnosis like lumbar puncture, blood test or electrolytes imbalanced. Physical Therapy consult- patient is on bedrest until evaluated by physical therapy. Vital signs and input/output every 8 hours. Right knee and elbow x-ray, patient diet is regular.

Secondary Medical Diagnoses
3 points
List and define all the patient’s secondary medical diagnoses (maximum of 10).
Differential diagnosis for multiple sclerosis includes Acute disseminated encephalomyelitis (Inflammation of brain and spinal cord), Sarcoidosis (growth of inflammatory cells in different body parts), Transverse myelitis (inflammation of both sides of a section of spinal cord). These differential diagnoses can be differentiated from multiple sclerosis through lab tests, MRI, and history taking.
References: Miller, D. H., Weinshenker, B. G., Fillipi (2008), Differential diagnosis of suspected multiple sclerosis.
Allergies
1 point
List all the patient’s allergies to food, medication, latex.
NOTE: Usually found in the provider orders. If the patient is allergy free from all of these, state “no known allergies to food, medication or latex”. The allergic reaction does not need to be listed.
No known drug allergies
Diet
1 point
Identify and describe the patient’s prescribed diet. Explain why this diet is appropriate for the patient.
The patient’s diet should contain more energy giving food and whole grain meal. This will help in providing the energy needed, hence prevent fatigue.
References: Payne, A (2001). Nutrition and diet in clinical management of multiple sclerosis.
Nursing Careplan 1 (15 Points)
Nursing Diagnosis (2 Points)
No more than 1 potential diagnosis may be used
Actual or Potential (1 Point)
Highlight actual or potential.
Expected Outcome (2 Points)
Identify 1 outcome that will show maintenance or improvement of the selected nursing diagnosis.
Ensure outcome is SMART:
Specific – Measurable – Attainable – Relevant – Timebound
Nursing Interventions
(3 Points)
Identify 3 patient specific interventions that will directly assist in meeting the expected outcome.
At least 2 must be action-driven interventions.
Rationales (3 Points)
Provide 3 rationales that validate why the intervention will assist in meeting the expected outcome.
One rationale per intervention.
Chronic pain
hour after providing nursing interventions, the patient will report an improvement in their level of comfort
4 hours after providing nursing interventions, the patient will report a significant reduction in pain severity levels (pain score <3/10) Upon discharge, the patient will be able to verbalize different pharmacologic and non-pharmacologic pain relief techniques which are available for them During the entire course of admission, no incidences of injury related to accidents should occur due to the patient's diplopia perception Upon discharge, the patient will be able to verbalize different measures required to promote safety and prevent injury related to disturbed visual perception in the home setting Encourage deep breathing exercise Apply warm compress at the affected area Place on high-Fowler's position To facilitate pharmacologic pain relief To increase oxygenation and act as a type of diversional activity to reduce pain To promote lung expansion and to decrease strain on the neck Related To (R/T) (2 Points) Describe the patient's specific situation and/or medical diagnosis that is directly linked to and causing the chosen nursing diagnosis. DO NOT state a medical diagnosis, but a description is appropriate. Chronic inflammation of the autoimmune system, which mistakenly attacks the healthy tissue of the CNS. Inflammation may activate due to (bacteria, virus, or chemicals) Administer PRN analgesics as ordered (e.g., acetaminophen, ibuprofen) Encourage diversional activity (e.g., watch TV, read Promote rest and discourage unnecessary mobilization and movements To promote local vasodilation and muscle relaxation to reduce tension and pain To reduce the risks of progressing pain To maximize the visual capacity of the patient and prevent accidents As Evidenced By (AEB) (2 Points) List all necessary supportive patient data to support the chosen nursing diagnosis (assessment findings, history, medications, labs, therapies, diet). This information proves your nursing diagnosis is appropriate. To increase oxygenation and act as a type of diversional activity to reduce pain To promote distraction and place focus away from pain Patient report severe neck pain and generalized muscle spasm, pain rate of 9 on a scale from 0-10. Flexeril 10 mg up to three times a day as needed Interferon beta- 1b (betaseron) 0.25 every other day subcutaneously Patient starts IV line-will be used to administer methylprednisolone daily IV for 5 days After completion of IV methylprednisolone, patient will be starting on oral prednisone to be tapered down and eventually stopped over the course of six days Add PRN med: Hydrocodone- acetaminophen (5-325) 1 tablet every four hours as needed for severe pain References: Stromberg, Holly. (2021). DeWitt's Medical-Surgical Nursing: Concepts and Practice, ed. 4, Pg 574 Oculomotor Nerve (Third Cranial Nerve): What Is It, Function & Anatomy (clevelandclinic.org) Janice, H. J., PhD RN, & PhD Rn, K. C. H. (2017). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (14th ed.). Wolters Kluwer. Tafti D, Ehsan M, Xixis KL. Multiple Sclerosis. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499849/ Nursing Careplan 2 (15 Points) Nursing Diagnosis (2 Points) No more than 1 potential diagnosis may be used Actual or Potential (1 Point) Highlight actual or potential. Expected Outcome (2 Points) Identify 1 outcome that will show maintenance or improvement of the selected nursing diagnosis. Ensure outcome is SMART: Specific - Measurable - Attainable - Relevant - Timebound Nursing Interventions (3 Points) Identify 3 patient specific interventions that will directly assist in meeting the expected outcome. At least 2 must be action-driven interventions. Rationales (3 Points) Provide 3 rationales that validate why the intervention will assist in meeting the expected outcome. One rationale per intervention. Risk for injury 1.During the entire course of admission, no incidences of injury related to accidents should occur due to the patient's double vision perception Upon discharge, the patient will be able to verbalize different measures required to promote safety and prevent injury related to diplopia (double vision) perception in the home setting. During the entire course of admission, no incidences of injury related to accidents should occur due to the patient's diplopia perception Upon discharge, the patient will be able to verbalize different measures required to promote safety and prevent injury related to diplopia (double vision) perception in the home setting Encourage the use of ambulatory assistive devices as needed or completely assist during ambulation Keep the floors always clean Always use adequate lighting in the room of the patient Refer to ophthalmology 1.To reduces the risk of accidental slips or falls related to decreased visual capacity during ambulation To prevent accidentally slipping on object on the floor due to decreased visual capacity to facilitate further assessment and management to improve their vision. Related To (R/T) (2 Points) Describe the patient's specific situation and/or medical diagnosis that is directly linked to and causing the chosen nursing diagnosis. DO NOT state a medical diagnosis, but a description is appropriate. Patient is having an impaired sensory function. There is a problem with the oculomotor nerve, which is the cranial nerve (CN III). Patient is having trouble controlling the muscle of the eyes which keeps it out of focus there is diplopia (double vision As Evidenced By (AEB) (2 Points) List all necessary supportive patient data to support the chosen nursing diagnosis (assessment findings, history, medications, labs, therapies, diet). This information proves your nursing diagnosis is appropriate. N/A References: Janice, H. J., PhD RN, & PhD Rn, K. C. H. (2017). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (14th ed.). Wolters Kluwer. Tafti D, Ehsan M, Xixis KL. Multiple Sclerosis. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499849/ assessment finding 02 sat 96% room air RR 18 TEM 98.5 F ALERT and oriented x3 6 gaze point intact double vision pain 3/10 to right knee and right forearm leg weakness, bruises to right knee and right elbow last bowel movement 1/26/2022 B/P 124/76 I NEED HELP REVISING AND IF MORE INFORMATION NEEDED. THANKS

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Subjective:
CC (chief complaint): “I was attacking mom.”
HPI: K.B. is a 9-year-old male accompanied by parents with a history of ADHD and Disruptive mood dysregulation disorder (DMDD) presenting for aggressive behaviors at home. The mother stated that he recently changed his school three months ago. A week ago, the patient was recently discharged from Cape Fear Valley Hospital emergency room after presenting for similar behaviors. The patient has aggressive behaviors and failed outpatient psychotherapy. He reports aggressive behaviors towards his mother without identifiable triggers, and he denies suicidal thoughts or self-injurious behaviors. He endorses homicidal ideations without plan towards his mother and younger brother. He denies auditory and visual hallucinations and does not appear to be responding to internal stimuli during the assessment. He does not have symptoms consistent with mania or hypomania. He denies significant anxiety. The parents report that he takes his prescribed medications at home. He denies having difficulty with sleep at home and maintains a good appetite. Father says that the patient has been physically aggressive towards his mother for the past few days. He also indicates that the patient receives intensive in-home therapy three times a week but has not improved with treatments. Father reports the patient often stays up at nighttime despite compliance with medications. Father states that the patient had genetic testing outpatient to determine suitable psychotropic medications and provided documentation with results. Father reports concern about the family’s safety with the patient’s recent behaviors without further inpatient treatment.
Past Psychiatric History:
General Statement: He has a history of ADHD and Disruptive mood dysregulation disorder (DMDD). He currently has intensive in-home therapy 3 x a week.
· Caregivers (if applicable): Father and mother.
· Hospitalizations: No history of hospitalization in the past.
· Medication trials: Multiple
· Psychotherapy or Previous Psychiatric Diagnosis: History of ADHD (attention deficit hyperactivity disorder), Bipolar 1 disorder, and DMDD (disruptive mood dysregulation disorder).
Substance Current Use and History: No history of alcohol, drug, or tobacco, caffeine use,
illicit drugs use, or exposure to secondhand cigarette smoke.
Family Psychiatric/Substance Use History: It is unknown family psychiatric or substance
history because he was adopted at age 2. No family history of suicide or homicide. The parents
deny any substance abuse problems.
Psychosocial History: The patient was adopted at age 2, was placed in foster care due to neglect
by parents. Education: fourth grade at elementary school, was homeschooled before September
of this year.
Family/Living situation: He lives with his parents, 8-year-old brother, and multiple dogs at
home. He was born and raised in North Carolina. He does not have past or current legal issues—
no history of trauma and no history of any violence or abuse.
Medical History:
· Current Medications: Clonidine 0.1 mg every morning and afternoon, 0.2 mg at nighttime.
Prozac 20 mg daily; Zyprexa 5 mg BID; Focalin 10 mg daily; Depakote 750 mg nightly;
melatonin 3 mg nightly; Remeron 7.5 mg nightly
· Allergies: Penicillin
Reproductive Hx: He is not sexually active.
ROS:
· GENERAL: He denies fever, recent weight gain, recent weight loss, chills, or intolerance to
heat or cold.
· HEENT: Head: He denies head trauma, dizziness, seizures, or headache. Eye: He denies
blurring of vision, eye pain, loss of vision, or eye discharge. Ear: He prohibits tinnitus, vision loss, ear discharge, and ear pain. Nose: He denies running nose, nose bleeding, sneezing, or nasal congestion. Throat: He denies sore throat, painful swallowing, hoarseness of voice, or difficulty in swallowing.
· SKIN: He denies itchiness or rashes.
· CARDIOVASCULAR: He denies edema, palpitations, chest pains, orthopnea, or shortness of
breath.
· RESPIRATORY: He denies cough, chest pains, fast breathing, sputum production, or difficulty
breathing.
· GASTROINTESTINAL: He has a history of losing appetite but denies abdominal pains,
diarrhea, nausea, vomiting, or constipation.
· GENITOURINARY: He denies burning sensation during urination, incontinence, hematuria,
hesitancy, or oliguria.
· NEUROLOGICAL: He denies dizziness, headache, syncope, numbness, ataxia, tingling
sensations, and paralysis.
· MUSCULOSKELETAL: He denies back pains, muscle pain, joint stiffness, or joint pain.[1]
Objective:
Physical examination: No physical examination will be needed for this patient.
Diagnostic results: complete blood count (CBC), comprehensive metabolic panel (CMP) tests necessary to rule out the anemia. Any infection, examine electrolytes to rule out renal disorder, and a thyroid function test to rule out thyroid disease. Blood studies and immunological evaluation for commercially were conducted. Platelet count was the only blood boundary for control status that was statistically significant (p=0.01) in a regression model controlling for age and gender differences (KRIVOSOVA et al., 2020).
Depakote level needs to be checked to maintain a therapeutic level. Plasma drug quantitation is used to check dose titration, compliance, and toxicity in treatment with antiepileptic drugs like valproic acid (VPA). However, without considering the pharmacokinetic principles due to the absence of clinical pharmacists in the Health System (del Rosario Hernández-Jerónimo et al., 2021). The diagnostic test conducted on the patient is a children’s depression inventory (CDI); according to Ahlen & Ghaderi (2017), The Children’s Depression Inventory-Short Version widely used Children’s Depression Inventory has been extensively used in recent research.
Assessment:
Mental Status Examination: He is a young Caucasian boy who is well-groomed, dressed appropriately. Behaviors are normal posture and sitting up in a chair—no apparent tics or tremors. Patient with good eye contact and is cooperative. Speech is regular in rate, rhythm, volume and is spontaneous. Thought processes are linear. Both his short-term and long-term memory is intact. He denies auditory and visual hallucinations and does not appear to be responding to internal stimuli. Thought content is without apparent delusions or paranoia. He reports his mood is “slightly depressed.” Affect is mildly dysphoric and mood congruent. The patient denies suicidal ideations, denies suicidal plans, endorses homicidal ideations, and denies homicidal intent. He is awake and alert—he has impaired concentration. Insight is limited. Judgment is limited. Reliability reveals patient dependable in interview information. He is oriented to person, place, and time. His cranial nerves were all intact.
Differential Diagnoses:
Disruptive mood dysregulation disorder (DMDD): According to DSM 5, severe recurrent temper outbursts manifested verbally and behaviorally out of portion to the situation, and inconsistent with developmental level Mood between bursts is persistently irritable or angry (American Psychiatric Association. 2013). DMDD describes behavior that is thought the abnormal range of childhood behavior; the crucial features of this disorder include severe recurrent temper outbursts manifested verbally and behaviorally that are out of portion in strength or duration to the situation or incitement (Gilea & O, N. R. M.,2015).
Pediatric major depressive disorder: Mental disorders affect 10-20 % of the young population in the world. Major depressive disorder (MDD) is a usual mental disease with a multifactorial and unclearly mentioned pathophysiology. Many cases stay undetected and untreated, which influences patients’ physical and psychological health and quality of life in adulthood (KRIVOSOVA et al., 2020). DSM 5 stated that depressed mood; loss of interest in activities or pleasure(anhedonia); insomnia or hypersomnia, agitation; fatigue or loss of energy; excessive guilt; decreased ability to concentrate; thoughts of death or suicide (American Psychiatric Association. 2013).
Pediatric bipolar disorder (PBD): DSM 5 listed persistently elevated or irritable mood; persistently increased energy or activity. Mania: inflated self-esteem or grandiosity; decreased need for sleep; pressured speech; racing thoughts distractibility; risky behavior (American Psychiatric Association. 2013). According to Gao et al. (2021), The present findings suggested that psychotic features in PBD were associated with extensive brain structural lesions located in the prefrontal-limbic-striatum circuit, which might represent the pathological basis of more severe symptoms in patients with psychotic PBD.
Pediatric generalized anxiety disorder: DSM 5 reports excessive distress with separation from home or caregivers; persistent worry about harm to caregivers; excessive worry about untoward event separating from a caregiver; extreme reluctance to be alone; ongoing separation; repeated physical symptoms when separating. Persistent problems or worry about attacks; significant behavior changes related to attack (American Psychiatric Association. 2013). Pediatric anxiety disorders are known, impairing, and often undertreated. Moreover, many youths do not respond to standard, evidence-based psychosocial or psychopharmacologic treatment. An increased understanding of the gamma-aminobutyric acid (GABA) and glutamate neurotransmitter systems has created opportunities for novel intervention development for pediatric GAD (Sonmez et al., 2020).
Reflections: I would first welcome the patient and his parents to the clinic to be comfortable. At first, I introduce myself. I would also for sure the parents inform them that everything that will be discussed will be confidential and therefore they should share everything that will be helpful.
Confidentiality: Maintaining confidentiality is an important way of adolescent health care. Different states and places have laws around confidential health care to minors for specific health concerns such as mental health and substance abuse. However, in situations where confidentiality cannot be assured if the adolescent is being abused. Educating teens and parents about the problems in which confidentiality is necessary (Alderman, 2017).
Ethical consideration: Rohan & Winter (2021) reported, children with chronic illnesses often have complex treatments that not only necessary a great deal of time and effort to manage but will also likely impact relationships with parents, siblings, and peers. Collaborating with a psychologist can help alleviate these unique challenges, positively impacting health behaviors and health outcomes.
Health Promotion: children’s primary care teams are routinely involved in many activities helping caregiver health, independent of training background despite many practice-related barriers. Co-location of support services could care the efforts of pediatric care teams. Future actions investigating care models that address these barriers and facilitators will help realize pediatric settings’ potential to impact adult health (Venkataramani et al., 2017). The health promotion of pediatric mental disorder educates the patient about his diagnosis and his family members about the condition. The family members are also critical since they will administer his prescribed treatment and ensure compliance.
Case Formulation and Treatment Plan: The patient demonstrates an elevated risk of harm to self or others currently. The patient requires medically necessary Inpatient Psychiatric Hospitalization to maintain safety and progress in treatment made to date. The discharge would cause regression of progress made and lead to rapid readmission. I would ensure that I remain attentive and maintain eye contact throughout the assessment. The assessment will also be performed in an orderly and professional manner and respect the parent’s decision not to answer or share any information. If it is urgent symptoms, decompensation, or thoughts of self-harms, call 911 or go to the emergency room. Mobil Crisis management is also available 24 hours and every day.
References
Ahlen, J., & Ghaderi, A. (2017). Evaluation of the Children’s Depression Inventory—Short Version (CDI-S). Psychological Assessment, 29(9), 1157.
Alderman, E. M. (2017). Confidentiality in Pediatric and Adolescent Gynecology: When We Can, When We Cannot, and When We are Challenged. Journal of Pediatric and Adolescent Gynecology, 30(2), 176-183. https://doi.org/10.1016/j.jpag.2016.10.003
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Https:///doi.org/101176/appi.books.9780890425596
del Rosario Hernández-Jerónimo, M., Chehue-Romero, A., Guadalupe Olvera-Hernández, E., Reyes-Hernández, I., Bermúdez-Camps, I. B., Ruíz-Anaya, M. E., & Robles-Piedras, A. L. (2021). Evaluation of the Appropriateness of Valproic Acid-Levels Monitoring in Mexican Pediatric Patients. Archives of Pharmacy Practice, 12(2), 1-5. https://doi.org/10.51847/rZTVWrCI1k
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