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Winningham's Critical Thinking Cases in Nursing Medical Solutions

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Winningham s Critical Thinking Cases in Nursing Medical Surgical Pediatric Maternity and Psychiatric 5th Edition by Mariann M Harding Julie

Musculoskeletal Disorders 3
Case Study 32 Osteoporosis
Difficulty: Beginning
Setting: Outpatient clinic
Index Words: osteoporosis, risk factors, treatment, medications
X Scenario
M.S., a 72-year-old white woman, comes to your clinic for a complete physical examination. She has not been to a provider for 11 years because “I don’t like doctors.” Her only complaint today is “pain in my upper back.” She describes the pain as sharp and knifelike. The pain began approximately 3 weeks ago when she was get-ting out of bed in the morning and hasn’t changed at all. M.S. rates her pain as 6 on a 0- to 10-point pain scale and says the pain decreases to 3 or 4 after taking “a couple of ibuprofen.” She denies recent falls or trauma.

M.S. admits she needs to quit smoking and start exercising but states, “I don’t have the energy to exercise, and besides, I’ve always been thin.” She has smoked one to two packs of cigarettes per day since she was 17 years old. Her last blood work was 11 years ago, and she can’t remember the results. She went through menopause at the age of 47 and has never taken hormone replacement therapy. The physical exam was unremarkable other than moderate tenderness to deep palpation over the spinous process at T7. No masses or tenderness to the tissue surrounded the tender spot. No visible masses, skin changes, or erythema were noted. Her neurologic exam is intact, and no muscle wasting is noted.

1. An x-ray examination of the thoracic spine reveals osteopenic changes at T7. What does this result mean?

2. The physician suspects osteoporosis. List seven risk factors associated with osteoporosis.

3. Place a star or asterisk next to those risk factors specific to M.S.

4. What diagnostic test is most commonly used to diagnose osteoporosis?

5. M.S.’s diagnostic test revealed a bone density T-score of –2.7. How will this be interpreted?

6. M.S. receives a prescription for alendronate (Fosamax) 70mg/week. Which instructions are appropriate as you provide patient teaching to M.S. about this drug? (Select all that apply.)

7. M.S. is also instructed to take a calcium plus vitamin D supplement. She asks, “If I am taking the osteoporosis pill, won’t that be enough?” How do you answer her?

8. What nonpharmacologic interventions will you teach M.S. to prevent further bone loss?

9. You encourage M.S. to start working on one problem at a time. Which problem should M.S. attempt first?

Case Study 33 Low Back Pain
Difficulty: Beginning
Setting: Hospital emergency department, home
Index Words: low back strain, rehabilitation, medications, risk factors
X Scenario

J.C. is a 41-year-old man who comes to the emergency department with complaints of acute low back pain. He states that he did some heavy lifting yesterday, went to bed with a mild backache, and awoke this morning with terrible back pain, which he rates as a “10” on a 1 to 10 scale. He admits to having had a similar episode of back pain years ago “after I lifted something heavy at work.” J.C. has a past medical his-tory of peptic ulcer disease (PUD) related to nonsteroidal anti-inflammatory drug (NSAID) use. He is 6 feet tall, weighs 265 pounds, and has a prominent “potbelly.”

1. What questions would be appropriate to ask J.C. in evaluating the extent of his back pain and injury?

2. What observable characteristic does J.C. have that makes him highly susceptible to low back injury? His potbelly puts undue strain on the lumbar joints, muscles, and tendons in his low back.

3. J.C. used to take piroxicam (Feldene) 20mg until he developed his duodenal ulcer. What is the relationship between the two? What signs and symptoms would you expect if an ulcer developed?

4. J.C. looks at the prescription for cyclobenzaprine (Flexeril) and states, “I’m glad you didn’t give me that Valium. They gave me Valium last time and that stuff knocked me out.” How would you respond to J.C.?

General instructions also include to avoid driving or using sharp objects until the response to the drug is known, but he is to stay off work for 5 days and in bed for the first 1 to 2 days.

5. Why do you think that cyclobenzaprine was prescribed instead of diazepam (Valium)?

6. J.C. states, “Well, I’m glad I’ll still be able to take my sleeping pill.” True or False? Explain.

7. Why do you think it was prescribed for J.C., considering his GI history?

8. You know that it has been over 5 years since his last episode of GI bleeding. Are there any other conditions that you need to assess for before J.C. begins to take the celecoxib? Explain.

9. Why would the NP prescribe an NSAID rather than acetaminophen for J.C.’s pain?

10. A physical therapist teaches J.C. maintenance exercises he can do on his own to promote back health. Identify two common exercises that would be included.

Case Study 34 Ankle Sprain
Difficulty: Beginning
Setting: Hospital emergency department
Index Words: trauma, sprained ankle, substance abuse, assessment, medications
X Scenario

D.M., a 25-year-old man, hops into the emergency department (ED) with complaints of right ankle pain.
He states that he was playing basketball and stepped on another player’s foot, inverting his ankle. You
note swelling over the lateral malleolus down to the area of the fourth and fifth metatarsals, and pedal
pulses are 3+ bilaterally. His vital signs are 124/76, 82, 18. He has no allergies and takes no medication.
He states he has had no prior surgeries or medical problems.

1. When assessing D.M.’s injured ankle, what should be evaluated?

2. What will initial management of the ankle involve to prevent further swelling and injury?

3. You note significant swelling over the fourth and fifth metatarsals. How would you further evaluate this

4. Describe the technique for applying an elastic wrap. Give the rationale.

5. When instructing D.M. to use crutches, D.M. states that he “likes it better” when the crutches rest under
his arms while walking with the crutches. Is this correct? Explain.

6. You instruct D.M. on using the three-point gait with the crutches. Which would be the correct first step
for the three-point gait?

7. You are to instruct D.M. on application of cold, activity, and care of the ankle. What would be
appropriate instructions in these areas?

8. D.M. is given a prescription for Lortab 2.5/500. Explain the meaning of the numbers.

9. What instructions concerning the Lortab are needed?

10. Four days later, D.M. hobbles into the ED and boldly informs you that he “did it again, only this time it
was touch football.” He states that the pain pills worked so well, he thought it would be OK. You detect
the odor of beer on his breath. What are you going to do?

11. You remove his sock and find a large hematoma forming on the lateral aspect of an already swollen
ankle. The ankle also shows the color of a bruise that is several days old. You inquire about D.M.’s pain
perception. He states, “It doesn’t feel too bad now, but I sure saw stars when it popped.” What is the
significance of his statement?

Index Words: arthroplasty, infection, rheumatoid arthritis (RA), risk factors, wound care, intraoperative
blood salvage, assessment, nutrition, rehab
X Scenario

S.P. is admitted to the orthopedic ward. She has fallen at home and has sustained an intracapsular
fracture of the hip at the femoral neck. The following history is obtained from her: She is a 75-year-old
widow with three children living nearby. Her father died of cancer at age 62; mother died of heart failure at
age 79. Her height is 5 feet 3 inches; weight is 118 pounds. She has a 50-pack-year smoking history and
denies alcohol use. She has severe rheumatoid arthritis (RA), had an upper gastrointestinal bleed in
1993, and had coronary artery disease with a coronary artery bypass graft 9 months ago. Since that time
she has engaged in “very mild exercises at home.” Vital signs (VS) are 128/60, 98, 14, 99° F (37.2° C),
SaO2 94% on 2 L oxygen by nasal cannula. Her oral medications are rabeprazole (Aciphex) 20 mg/day,
prednisone (Deltasone) 5 mg/day, and methotrexate (Amethopterin) 2.5 mg/wk.

1. List at least four risk factors for hip fractures.

2. Place a star or asterisk next to each of the responses in question 1 that represent S.P.’s risk factors.
All of them are applicable.

3. Why is the patient receiving enoxaparin (Lovenox) and warfarin (Coumadin)?

4. S.P. had an arthroplasty. For each characteristic listed, mark A for arthroplasty and O for open
reduction and internal fixation (ORIF) of the hip.

5. S.P. received blood as an intraoperative blood salvage. Which statements about this procedure are
true? (Select all that apply.)

6. List four critical potential postoperative problems for S.P.

7. How will you monitor for excessive postoperative blood loss?

8. According to the lateral traditional surgical approach, there are two main goals for maintaining proper
alignment of S.P.’s operative leg. What are they, and how are they achieved?

9. Postoperative wound infection is a concern for S.P. Describe what you would do to monitor her for a
wound infection.

10. Taking S.P.’s RA into consideration, what interventions should be implemented to prevent
complications secondary to immobility?

11. What predisposing factor, identified in S.P.’s medical history, places her at risk for infection, bleeding,
and anemia?

12. Briefly discuss S.P.’s nutritional needs.

13. Explain four techniques you can teach S.P. to help her protect herself from infection related to
medication-induced immunosuppression.

14. What factors need to be taken into consideration when choosing a rehabilitation facility?

H.K. is a 26-year-old man who tried to light a cigarette while driving and lost control of his truck. The truck
flipped and landed on the passenger side. H.K. was transported to the emergency department with a
deformed, edematous right lower leg and a deep puncture wound approximately 5 cm long over the
deformity. Blood continues to ooze from the wound.

1. What further assessment will you make of the leg injury, and what precautions will you take in making
this assessment?

2. What is the most appropriate method for controlling bleeding at this wound site?

3. From the above information, it is clear that H.K. is a smoker. List at least three issues related to his
smoking that can complicate his care and recovery. What interventions could be instituted to counter
these complications? Would using a nicotine patch eliminate these problems?

4. What is the best way to immobilize the leg injury before surgery?

5. Describe the assessment of a patient with a long leg cast involving trauma and surgery.

6. In assessing H.K.’s cast on the third day postoperatively, you notice a strong foul odor. Drainage on the
cast is extending, and H.K. is complaining of pain more often and seems considerably more
uncomfortable. Vital signs are 123/78, 102, 18, 102.2° F (39º C). What is your analysis of these findings?

7. Why are two antibiotics ordered?

8. H.K. asks you about the isolation precautions. “Does this mean I have something bad?” What is your
best answer?

9. As you continue to assess H.K. over the following days, what evidence will you look for that antibiotics
are effectively treating the infection?

10. What will H.K. be taught concerning the care of his cast?

11. What nutritional needs will H.K. have, and why?

12. To ensure pain management, H.K. is given a fentanyl (Duragesic) 75mcg/hr transdermal patch. To
which therapeutic category does this drug belong? What signs and symptoms would you see if he were to
have a toxic or overdose reaction?

13. What is the first thing you will need to do if you note a toxic or overdose reaction to the fentanyl
transdermal patch?

14. What is the antidote to toxic opioid reactions, and how is it administered?

15. What issues would the discharge planner need to address with H.K.?

M.M., a 76-year-old retired schoolteacher, underwent open reduction and internal fixation (ORIF) for a
fracture of his right femur. His preoperative control prothrombin time (PT/INR) was 11 sec/1.0 and his
aPTT was 35 seconds. He has been on bed rest for the first 2 days postoperatively. At 0600, his vital
signs were 132/84, 80 with regular rhythm, 18 unlabored, and 99° F (37.2° C). He is awake, alert, and
oriented with no adventitious heart sounds. Breath sounds are clear but diminished in the bases
bilaterally. Bowel sounds are present, and he is taking sips of clear liquids. An IV of D5 ½ NS is infusing
75 mL/hr in his left hand and orders are to change it to a saline lock in the morning if he is able to
maintain adequate PO fluid intake. He has orders for oxygen (O 2) to maintain SaO2 over 92%. His lab
work shows Hct, 34%; Hgb, 11.3 mg/dL; K, 4.1 mEq/L; aPTT, 44 sec. Pain is controlled with morphine
sulfate 4 mg IV as needed every 4 hours, and he has promethazine (Phenergan) 25 mg IV q3h if needed
for nausea. He is also receiving heparin 5000 unit

2. Using SBAR, what information, based on the findings, would you provide to the physician when you

3. The physician orders that the patient be transferred to ICU and have blood coagulation studies, arterial
blood gases (ABGs) on room air, continuous pulse oximetry, STAT chest x-ray (CXR), and STAT 12-lead
ECG. What information will the physician gain from each of the above?

4. Why would the physician order ABGs on room air as opposed to with supplemental O 2?

5. What is your interpretation of the ABGs, and what do you think the physician will ordernext?

6. What are the most likely sources of the embolus?

7. For each characteristic listed in the following, note whether it is a characteristic of a fat embolus (F), a
blood clot embolus (BC) in the lungs, or both (B)

8. Before the latest PTT/INR results are back, the physician orders a heparin bolus of 5000 units IV
followed by an infusion of 1200 units/hr. The lab calls with a critical value—the aPTT is 120 seconds.
Based on these results, what action will you take?

9. The physician is considering administering an antidote to the heparin. Which generic drug is
considered an antidote to heparin therapy?

10. The next day the physician’s orders read, “Warfarin (Coumadin) 2.5mg PO, PT/INR in am; D/C
heparin.” What is wrong with these orders?

11. Some thrombolytics, such as alteplase (Activase), have been beneficial in the treatment of PE. Would
M.M. be a candidate for treatment with thrombolytics? Why or why not?

12. List three priority problems related to the care of M.M. in his current situation.

J.F., a 67-year-old woman, was involved in an auto accident and is flown by emergency helicopter to your
facility. She sustained a ruptured spleen, fractured pelvis, and compound fractures of the left femur. On
admission (5 days ago) she underwent a splenectomy. Her pelvis was stabilized with an external fixation
device 3 days ago, and, yesterday, her left femur was stabilized using balanced suspension with skeletal
traction. She has a Thomas splint with a Pearson attachment on her left leg. She has 20 pounds of skeletal traction and 5 pounds applied to the balanced suspension. Her left femur is elevated off of the bed at
approximately 45 degrees. The lower leg is parallel to the bed and lies in a sling that the nurse adjusts on
the frame, and the foot hangs freely. This morning, J.F. was transferred to your orthopedic unit for
specialized care. You are the nurse assigned to care for her on the night shift.

1. You enter J.F.’s room for the first time. What aspects of the traction will you inspect?

2. When inspecting the skeletal pin sites, you note that the skin is reddened for an inch around the pin on
both the medial and lateral left leg. What does this finding indicate, and what action will you take?

3. What key points of the assessment will you document in the patient’s record?

4. You find J.F.’s body in the lower 75% of the bed, and her left upper leg is at an exaggerated angle
(more than 45 degrees). The knot at the end of the bed is caught in the pulley, and the 20-pound weight
is dangling just above the floor. What are you going to do?

5. When you lift J.F., you notice that her sheets are wet. You decide to change J.F.’s linen. How would
you accomplish this task?

6. J.F. tells you that she feels like she needs to have a bowel movement (BM), but it is too painful to sit on
the bedpan. How would you respond?

7. J.F. expels a few small, hard, round pieces of stool. What could be done to promote normal

You ask J.F. whether she is ready for her bath, and she responds positively. You let her bathe the parts
she can reach and engage her in a conversation as you attend to the rest of her body. While performing
perineal care, you notice that the folds of skin around her perineal area are reddened and excoriated.

8. Given that J.F. has been on antibiotics for the past 5 days, what is the likely cause of the problem, and
what needs to be done to encourage healing?

9. You ask J.F. what she is doing to exercise while she is confined to the bed. She looks surprised and
states that she isn’t doing anything. What activities can J.F. engage in while on bed rest?

10. You realize that maintaining skin integrity is a challenge in J.F.’s case. What measures will you take to
prevent skin breakdown?

11. Although J.F. is recovering nicely, she is becoming increasingly withdrawn. You enter her room and
find her crying. She tells you that she is all alone here, that she misses her family terribly. You know that
her son is flying into town tomorrow but will only be able to stay a few days. What can be done so that
J.F. benefits from her family support system?

You are working in the emergency department when M.C., an 82-year-old widow, arrives by ambulance.
Because M.C. had not answered her phone since noon yesterday, her daughter went to her home to
check on her. She found M.C. lying on the kitchen floor, incontinent of urine and stool, with complaints of
pain in her right hip. Her daughter reports a past medical history of hypertension, angina, and osteoporosis. M.C. takes propranolol (Inderal), a nitroglycerin patch, indapamide (Lozol), and conjugated estrogen
(Premarin) daily. The daughter reports that her mother is normally very alert and lives independently. On
examination, you see an elderly woman, approximately 100 pounds, holding her right thigh. You note
shortening of the right leg with external rotation and a large amount of swelling at the proximal thigh and
right hip. M.C. is oriented to person only and is confused about place and time, but she is able to say that
her “leg hurts so bad.” M.C.’s vital signs (VS) are 90/65, 120, 24, 97.5 ° F (36.4 ° C); her SpO2 is 89%.
She is profoundly dehydrated. Preliminary diagnosis is a fracture of the right hip.

1. Considering her medical history and that she has been without her medications for at least 24 hours,
explain her current VS.

2. Based on her history and your initial assessment, what three priority interventions would you expect to
be initiated?

3. M.C.’s daughter states, “Mother is always so clear and alert. I have never seen her act so confused.
What’s wrong with her?” What are three possible causes for M.C.’s disorientation that should be
considered and evaluated?

4. What laboratory and diagnostic studies will be ordered to evaluate M.C.’s condition, and what critical
information will each give you?

5. What are the five P’s that should guide the assessment of M.C.’s right leg before and after surgery?

6. In evaluating M.C.’s pulses, you find her posterior tibial pulse and dorsalis pedis pulse to be weaker on
her right foot than on her left. What could be a possible cause of this finding?

7. In planning further care for M.C., list four potential complications for which M.C. should be monitored.
• Risk for fat emboli is high in the presence of long bone fracture.

8. M.C. keeps asking about “Peaches.” No one seems to be paying attention. You ask her what she
means. She says Peaches is her little dog, and she’s worried about who is taking care of it. How will you

9. As you assess the Buck’s traction, you check the setup and M.C.’s comfort. Which of these are
characteristics of Buck’s traction? (Select all that apply.)

10. Ultram and Lortab are both constipating. What will you do to prevent constipation?

11. Between her admission at 1500 and the next day, she has received five doses of the Lortab and two
doses of the acetaminophen (Tylenol). At 1300, she develops a fever of 101° F (38.3° C), and the
physician writes an order to give acetaminophen (Tylenol), 650mg PO every 4 hours for temperature over
100.5 ° F (38.1° C). Is there a concern with this order?

E.B., a 69-year-old man with type 1 diabetes mellitus (DM), is admitted to a large regional medical center
complaining of severe pain in his right foot and lower leg. The right foot and lower leg are cool and without pulses (absent by Doppler). Arteriogram demonstrates severe atherosclerosis of the right popliteal
artery with complete obstruction of blood flow. Despite attempts at endarterectomy and administration of
intravascular alteplase (tissue plasminogen activator [TPA]) over several days, the foot and lower leg
become necrotic. Finally, the decision is made to perform an above-the-knee amputation (AKA) on E.B.’s
right leg. E.B. is recently widowed and has a son and daughter who live nearby. In preparation for E.B.’s
surgery, the surgeons wish to spare as much viable tissue as possible. Hence, an order is written for E.B.
to undergo 5 days of hyperbaric therapy for 20 minutes bid.

1. What is the purpose of hyperbaric therapy?

2. You look at his chart and find no advance directives. What is your responsibility?

3. What is your assessment of E.B.’s behavior at this time?

4. What are some appropriate interventions and responses to E.B.’s anticipatory grief?

5. The surgeon has written to keep E.B.’s stump elevated on pillows for 48 hours; after that, have him lie
in a prone position for 15 minutes, four times a day. In teaching E.B. about his care, how will you explain
the rationale for these orders?

6. In reviewing E.B.’s medical history, what factors do you notice that might affect the condition of his
stump and ultimate rehabilitation potential?

7. Identify four interventions that would facilitate timely healing of E.B.’s stump.

8. What should the postoperative assessment of E.B.’s stump dressing include?

9. You are reviewing the plan of care for E.B. Which of these care activities can be safely delegated to the
nursing assistive personnel (NAP)? (Select all that apply.)

10. 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?

11. What is causing E.B.’s pain?

12. What instructions should be given to E.B.’s daughter concerning safety around the home?

J.T. has injured his hand at work and is accompanied to the emergency department (ED) by a co-worker.
You examine his left hand and find a piece of a drill bit sticking out of the skin between the third and
fourth knuckles. There is another puncture site about an inch below and toward the center of the hand.
Bleeding is minimal. J.T. is 41 years old, has no significant medical history, and has no known drug allergies. He states the accident occurred when a mill at work malfunctioned and knocked his hand onto a
rack of drill bits. His last tetanus booster was 12 years ago. It is your job to provide the initial care for
J.T.’s injury.

1. You examine J.T.’s hand. What is the priority action? What should you include in your initial
assessment, and why?

2. You notice J.T.’s wedding band and promptly ask him to remove it. Why is this important?

3. J.T. asks you why the doctor can’t just pull the bit out and then he can go home. How should you
respond to his question?

4. What common diagnostic test will identify fractures and the location of metal fragments in J.T.’s hand?

5. You accompany the surgeon to J.T.’s bedside and listen to the explanation of the surgery, and then
you witness J.T. signing the surgical consent form. What do you need to do to prepare J.T. for immediate

6. How will you verify that he understands about the surgical procedure?

7. You record that J.T. has had no food “since 8:00 pm yesterday” and drank “some water” this morning.
Based on this information, do you anticipate problems during surgery, and why?

8. Does J.T. need a tetanus booster? If so, will he receive a Td or Tdap? Explain your answer, based on
the latest Centers for Disease Control and Prevention (CDC) guidelines.

9. While in the short-stay recovery area, J.T. asks the nurse why his fingers look yellowish brown. How
should she respond to his question?

10. Which statement by J.T. indicates that further teaching about the medications is needed?

11. What additional instructions should the nurse in the short-stay area discuss with J.T. and his wife
before releasing him?

12. J.T. says, “How in the world is the ice supposed to keep my hand cold with this big bandage on it?”
How will the nurse reply?

13. J.T. says, “I’ll be able to keep my hand up when I’m awake, but what about when I go to sleep?” What
suggestion can the nurse make to help J.T. comply with the instructions?




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