4BS FY15 Case Study

1. On the evening of the first postoperative day, E.B. becomes more awake and begins to complaining of (C/O) pain. He states, "My right leg is really hurting; how can it hurt so bad if it's gone?" What is your best response?

“That is a side effect of the medication.”

“You can't be feeling that because your leg was amputated.”

“Don't worry, that sensation will go away in a few days.”

“Are you able to rate that pain on a scale of 1 to 10?”

The best response is to ask the patient to rate the pain on a scale of 1 to 10. This allows the healthcare provider to assess the severity of the pain and determine the appropriate course of action. It also shows empathy and concern for the patient's well-being.

Explanation

The best response is to ask the patient to rate the pain on a scale of 1 to 10. This allows the healthcare provider to assess the severity of the pain and determine the appropriate course of action. It also shows empathy and concern for the patient's well-being.

2. 84 Year old confused patient with UTI; Dr. C. M. Pea.The LPN comes to tell you that the patient is very confused, trying to get out of bed..."was a little confused at the beginning of the shift, but nothing like this." What is the FIRST nursing action to ensure the patient's safety?

Re-orient the patient and activate the bed alarm

Call the physician for an order for restraints

Call the physician for an order for Ativan

After making your nursing rounds, go in and check on the patient

The first nursing action to ensure the patient's safety in this scenario is to re-orient the patient and activate the bed alarm. This is important because the patient is confused and attempting to get out of bed, which puts them at risk for falls or injury. By re-orienting the patient, the nurse can help them regain their orientation and understanding of their surroundings. Activating the bed alarm will alert the nursing staff if the patient tries to get out of bed, allowing for prompt intervention and prevention of falls.

Explanation

The first nursing action to ensure the patient's safety in this scenario is to re-orient the patient and activate the bed alarm. This is important because the patient is confused and attempting to get out of bed, which puts them at risk for falls or injury. By re-orienting the patient, the nurse can help them regain their orientation and understanding of their surroundings. Activating the bed alarm will alert the nursing staff if the patient tries to get out of bed, allowing for prompt intervention and prevention of falls.

3. After not having any emesis and not having any frank red blood in his stool or "black tarry stools" over the past 5 hours, you contact the physician about the other symptoms the patient is displaying. You anticipate the physician starting what protocol?

Stroke

Chest Pain

CIWA

None of these

Based on the given information, the patient is not experiencing symptoms related to stroke or chest pain. The mention of CIWA (Clinical Institute Withdrawal Assessment) suggests that the patient may be displaying symptoms of alcohol withdrawal. CIWA is a protocol used to assess and manage alcohol withdrawal symptoms.

Explanation

Based on the given information, the patient is not experiencing symptoms related to stroke or chest pain. The mention of CIWA (Clinical Institute Withdrawal Assessment) suggests that the patient may be displaying symptoms of alcohol withdrawal. CIWA is a protocol used to assess and manage alcohol withdrawal symptoms.

4. You are reviewing the plan of care for E.B. Which of these care activities can be delegated to the LPN? (Select all that apply.)

Rewrapping the stump bandage

Checking E.B.'s vital signs

Changing E.B.'s PICC line dressing

Assisting E.B. with repositioning in the bed

Asking E.B. to report his level of pain on a 1-to-10 scale

The LPN can rewrap the stump bandage, check E.B.'s vital signs, assist E.B. with repositioning in the bed, and ask E.B. to report his level of pain on a 1-to-10 scale. These activities do not require advanced nursing skills and can be safely delegated to the LPN. Changing E.B.'s PICC line dressing, on the other hand, requires a higher level of expertise and should be performed by a registered nurse.

Explanation

The LPN can rewrap the stump bandage, check E.B.'s vital signs, assist E.B. with repositioning in the bed, and ask E.B. to report his level of pain on a 1-to-10 scale. These activities do not require advanced nursing skills and can be safely delegated to the LPN. Changing E.B.'s PICC line dressing, on the other hand, requires a higher level of expertise and should be performed by a registered nurse.

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5. You are working night shift on a medical/surgical unit caring for 4 patients. There are 2 other RN's on the unit that has a similar assignment. there is one LPN on the unit to help all of you.Below is the list of your patients with their diagnosis, PMH as well as the admitting MD:

Patient Age	Admitting Diagnosis	PMH	Doctor

74 year old	confused w/UTI	CAD, dementia	Dr. C. M. Pea
69 year old	AKA	DM	Dr. Hatchet
57 year old	GI bleed/alcohol intoxication	ETOH,	Dr. Shake
39 year old	Appendicitis	No significant PHM	Dr. Payne

Prioritize patients based on whom you would see first.

74 year old confused with UTI

69 year old AKA

57 year old GI Bleed/alcohol intoxication

39 year old Appendectomy POD #2

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6. 57 year old patient GI bleed/alcohol intoxication; Dr. Shake J.G., a 57-year-old man, was seen in the emergency department (ED) 2 days ago, diagnosed (Dx) with alcohol intoxication, and released after 8 hours to his brother's care. He was brought back to the ED 12 hours ago with an active gastrointestinal (GI) bleed and is being admitted; his diagnosis is upper GI bleed and alcohol intoxication. According to the report received, his admission vital signs (VS) were 84/56, 110, 26, and he was vomiting bright red blood. His labs were remarkable for Hct 23%, alanine transaminase (ALT) 69 IU/ml, aspartate transaminase (AST) 111 IU/ml, and serum alcohol (ETOH) 271 mg/dl. He was given IV fluids and transfused 6 units of packed RBCs (PRBCs) in the ED. On initial assessment, you note that J.G.'s VS are blood pressure (BP) 180/110 mm Hg, pulse 120 beats/min; he has a slight tremor in his hands, and he appears anxious. He complains of a headache and appears flushed. You note that he has not had any emesis and has not had any frank red blood in his stool or "black tarry stools" over the past 5 hours. In response to your questions, J.G. denies that he has an alcohol problem but later admits to drinking approximately a fifth of vodka daily for the past 2 months. He reports having been drinking just before his admission to the ED. He admits to having had seizures while withdrawing from alcohol in the past.Which data from your assessment of J.G. are of concern to you? [Select all that apply]

Elevated BP and heart rate

Tremor, appearing anxious and flushed

Headache

Amount and frequency of alcohol use

History of seizure with withdrawal from alcohol

The elevated blood pressure and heart rate, tremor, appearing anxious and flushed, headache, and history of seizure with withdrawal from alcohol are all concerning findings in the assessment of J.G. These symptoms suggest that J.G. may be experiencing alcohol withdrawal syndrome, which can be life-threatening if not managed properly. The high blood pressure and heart rate may indicate autonomic hyperactivity associated with withdrawal. The tremor, anxiety, and flushed appearance are also consistent with alcohol withdrawal symptoms. Additionally, J.G.'s history of seizures with alcohol withdrawal further supports the concern for alcohol withdrawal syndrome. The amount and frequency of alcohol use are also important to assess in order to determine the severity of J.G.'s alcohol dependence and guide appropriate treatment.

Explanation

The elevated blood pressure and heart rate, tremor, appearing anxious and flushed, headache, and history of seizure with withdrawal from alcohol are all concerning findings in the assessment of J.G. These symptoms suggest that J.G. may be experiencing alcohol withdrawal syndrome, which can be life-threatening if not managed properly. The high blood pressure and heart rate may indicate autonomic hyperactivity associated with withdrawal. The tremor, anxiety, and flushed appearance are also consistent with alcohol withdrawal symptoms. Additionally, J.G.'s history of seizures with alcohol withdrawal further supports the concern for alcohol withdrawal syndrome. The amount and frequency of alcohol use are also important to assess in order to determine the severity of J.G.'s alcohol dependence and guide appropriate treatment.

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4bs Fy15 Case Study