Case Studies Test Questions – Flashcards

R.T., a 16 year old male, is involved in a serious ATV accident in which he is the only survivor. Two ATVs collided, causing an explosion and fire in which RT is severely burned. He has full thickness burns covering 90% of his body, including his face. RT is flown to the QEII Health Sciences Centre and admitted to Intensive Care. 1.1) How is RTs "first line of defense" against foreign invaders affected by his burns? What type of cellular damage does this now place RT at risk for?

RT has now been in Intensive Care for several days. He edematous, has a temperature of 39.2 and is requiring high levels of narcotics to manage his pain. He is unable to move his own body at all in bed. His WBC count is elevated at 22.1 and RT is oozing blood from all of his wound beds, causing his hemoglobin to drop to 68 and his blood pressure to be low at 82/40. 1) As the bedside nurse caring for RT, what symptoms of inflammation do you note RT is experiencing? Why is RT requiring high levels of narcotics to manage his pain?

2) What blood products might you administer to help stop the oozing of blood from RTs wounds?

3) The blood is taking a while to arrive onto the unit from the blood bank. You need to administer some IV fluid to help support RTs blood pressure until the blood product arrives. Would you administer 0.9 NS (isotonic IV solution), D5W (hypotonic IV solution), or 3% Saline (a hypertonic IV solution)?

4) As a RN, what are some other important considerations to keep in mind in order to ensure optimal healing of RTs wounds?

If RT was to have a transfusion reaction in the future, what type of hypersensitivity reaction would he be experiencing?

As the bedside nurse, if you noted RT was having a transfusion reaction, what would be the very first action you would take to stop the reaction?

EK, a 22 year old university student, presents to the Emergency Department. She complains of a very stiff and sore neck, fever, chills and exhaustion, a headache and feeling "like she is going to throw up". She also complains that "the lights are way too bright in here" and seems extremely irritable. Upon you physical assessment of EK you note that she is unable to touch her chin to her chest or fully turn her head side to side. You also note that her deep tendon reflexes appear to be exaggerated and that when you attempt to flex EK's neck she passively flexes her lower limbs (positive Brudzinski's sign). During your physical assessment EK informs you that she has had a sinus infection for the past two weeks, which she had been taking antibiotics for. EK has a temperature of 39.2 and her heart rate is elevated at 114 bpm. 1) Based on your physical assessment and what EK has told you, what do you suspect the cause of EK's symptoms to be?

2)What tests or procedures, if any, would you be prepared to do or assist with as EK's nurse in the emerg department?

The ERP (emergency room physician) has completed a lumbar puncture and while you are assisting her in collecting the CSF (cerebral spinal fluid), you note that EK's CSF looks cloudy and appears to be slightly thick.

2)You are filling out the requisition to have the CSF processed in the lab. What tests will you check off to have run on the CSF?

The ERP would like EK to be admitted for observation. There is no bed available at this time, so EK must stay in your pod in emerg and you must monitor her as well as care for the other patients that are coming and going. While you are busy helping an elderly lady to the toilet, EK vomits and then falls asleep on the stretcher. When you go to check on her, she is very difficult to wake up and unable to keep her eyes open to focus on you. 1)What is your primary concern for EK?

2) What do you suspect may have caused her to vomit and become so difficult to rouse?

EK is transferred to the neurosurgery IMCU. What do you think will be the course of her treatment there?

M.K, a 38 year old mother of two, is diagnosed with stage 4 breast cancer. She is a non smoker and breast fed both of her children for one year. Both her mother and grandmother died of cancer that originated in their breasts. She undergoes a double mastectomy, treatment with chemotherapy and some radiation to the surgical sites post operatively. The surgeons remove the lymph nodes in her axilla as well as her breasts. 1) What are the defining characteristics of stage four cancer?

2)What risk factors did MK have for developing breast cancer? Specifically genetic risk factors.

3)What failed to happen in MK's immune system when she developed this cancer?

4)What types of treatments were given to MK? What are the side effects and potential complications of these treatments?

One year post treatment and into remission, MK begins to notice she is having difficulty breathing and that she is again rapidly losing weight. One night after playing with her children she becomes acutely short of breath and her husband has to take her to the emergency department. A chest XRay shows that MK has a large pleural effusion on her left lung that is restricting her ability to breathe. A chest tube is inserted to drain the effusion and immediately upon insertion it drains one litre of pleural fluid mixed with a bit of blood. MK is admitted to thoracic surgery and a PET scan shows that she has a large tumor in her left lung, as well as metastasis to her liver and bones. MK's prognosis is very poor and she opts for no further surgery or aggressive treatment. She is offered radiation to shrink the tumour to help with her breathing as well as pain related to the bone mets, and a permanent type of chest tube called a Tenckoff catheter that she can use at home to drain her pleural effusion when she becomes short of breath. 1)What type of treatment is MK now receiving for her cancer? Specifically, what are the goals of care for MK?

2)What is the primary source of cancer in the MK's body?

Describe what metastasis is and how the cancer may have spread throughout MK's body.

BL, an active 23 year old male, is taken to emergency following an accident in which while swimming intoxicated, BL dove into the shallow area of the lake and severely jarred his head and neck. BL is alert, has labored breathing with excessive accessory muscle to his shoulders, and is not moving below his nipple line. He tells you that he "can't feel anything" under his clavicle. You are relieved to note that BL is wearing an aspen collar and is on a backboard to keep him immobile. BL's heart rate is 43 and his blood pressure is 85/50. 1) What injury do you suspect BL to have and at what level of his spinal column? Most importantly, why might BL be having difficulty breathing?

2) Why are you relieved to note BL's neck is immobilized and he is on a back board?

3) What tests, specifically imaging, will BL need to diagnose his injury

BL's CT scan shows him to have a complete cord injury at the level of C6. Currently he has some gross motor movement of his shoulders. 1) What is BL's treatment now that he has a diagnosis?

2) Based on the dermatome chart in your lecture, where do you expect BL's sensation will end on his body?

GD, a 65 year old man who has a PMHX of a 40 pack year smoking history, COPD, diabetes and chronic renal failure is admitted for an exacerbation of COPD and acute on chronic renal failure. You are told that he reports his urine output has been minimal the last few days, and he hasn't been following his renal diet. GD has been ++ short of breath and wheezy. An arterial blood gas and some electrolytes were sent. You have the result of the ABG and it is as follows: Ph 7.18,pCo2 78,pO2 58,Hc03 34,Spo2 88,K 6.1 1) What type of acid base imbalance does GD's ABG show him to have? Is he in a respiratory or metabolic acidosis? Is it fully or partially compensated (or not compensated at all)? HCO3 is a base.

You take note of GD's potassium of 6.1. Is this a normal potassium level?

1) What are some of the possible effects of GD's potassium level that you may see when assessing him?

2) Knowing that GD has an acute on chronic renal failure, and that he reports peeing very little over the last few days and not following his renal diet, what do you suspect the cause of his high potassium level to be?

What happens to cells that are exposed to an acidic environment? How low can a PH be before it is considered "incompatible with life'?

Mr. T, a 63 year old man presents with severe sob. He reports being unable to breath while lying flat, and states that he has been sleeping in a chair or bent over his table. He is sitting on the edge of the stretcher in the "tripod" position. You note that he is using pursed lip breathing, has accessory muscle use while breathing and has a noticeable barrel chest. Mr T's medical history is hypertension, and he reports smoking "two packs a day since I was a teenager". you hear distant wheezes throughout. Mr T. also has a productive cough which he states he lives with on a regular basis but seems to be a bit worse lately. His arterial blood gas shows that he has a normal PH of 7.36, a elevated PCO2 of 60, an elevated HCO3 of 30 and a low PO2 of 64. 1) Based on Mr. T's history, symptoms and physical appearance, what chronic illness do you suspect he is suffering from?

2) What other tests would be run on Mr T to ensure he is properly treated?

3) What would be the goals of care and possible medications/treatments that Mr T. would be given?

Mr. T is admitted to the general medicine floor. At 0230 he wakes from sleep and rings his call bell. When the nurse enters the room he is so short of breath he has trouble getting his words out. He is able to tell the nurse he is having crushing chest pain, as if an elephant is sitting on his chest. He feels sick to his stomach and vomits. 1) Again, based on Mr. T's hx of smoking, hypertension and the symptoms he is currently experiencing, do you think is happening to Mr T?

2) As the nurse, what are the first interventions you would implement to help Mr T?

You are working a nightshift in the neurosurgical stepdown unit and are caring for a patient that was admitted from the operating room late on the dayshift. This patient is 54, and has had surgery on her pituitary gland to remove a tumor. The surgery was done via a transphenoidal approach (through the patients nose) and both the anterior and posterior portions of the gland were affectes. You note when reviewing her medication record that you are to begin admininstering her several medication. One of these is a steroid, methylprednisone. Another is synthetic form of thyroid hormone, levothyroxine. The neurosurgeon who did the surgery seems very adamant and concerned that the patient receives these medications promptly and exactly as ordered. 1) You have seen similar medications ordered for other patients you have cared for. Why is it so important that this particular patient receives these medications promptly and exactly as ordered?

2) The neurosurgeon tells you that this patient will be on these steroids and synthetic thyroid hormone for the rest of her life. Why is this?

At four in the morning you note when you are doing the intake and output for your shift you note that your post op pituitary tumour patient has had very high urine output. Her urine is extremely clear and colorless. You also have sent some bloodwork on this patient and note that her serum sodium is climbing (it was 142 six hours ago, it is now elevated at 148). 3)Based on the patients surgery and what it can affect in her body, what are concerned may be happening to your patient? I.e. why is she having high urine output and high serum sodium.

What do you suspect may be ordered by a physician to treat this condition?

Explain the hormonal changes that occur during the menstrual cycle and cause the onset of menstruation (endometrial sloughing). 1) Follicular Phase

Ovulatory Phase

Luteal Phase

Mrs. K, a 82 year old widow who lives alone on a fixed income has presented to the emergency department with a complaint of nausea and cramping. She has had a significant weight loss in the last year and reports her daily food intake consists mainly of tea and toast. Her abdomen is distended and when asked she reports her bowels haven't moved in over a week. An abdominal flat plate XRay is done and fecal overload is noted on the XRay. Some blood work is done and it shows that Mrs. K has a high serum osmolality of 315 and a low prealbumin of 71. 1) What are some possible reasons that Mrs. K food intake is so low and she is eating mainly toast and drinking mainly tea?

2) What is the possible cause of Mrs. K's fecal overload (severe constipation) and why is she nauseas?

3) Why are Mrs. K's osmolality and prealbumin significant?

4) What are some possible treatments for Mrs. K's constipation and if her constipation is not resolved what is she at risk for?