CASE STUDY ONE: Mr Dan Smith
Mr Dan Smith is a 42-year-old mechanic who sustained a minor head injury and fracture of his Right distal tibia and fibula in a motor bike accident. He was brought into University Hospital last night by ambulance where he has been admitted to Ward 1B at University Hospital. He is awaiting an open reduction and internal fixation (surgical repair) of his fracture.
Socially, Dan loves riding his motor bike and is a regular at the Australian MotoGP. He owns his own business and lives with his 7-month pregnant partner.
His has an unremarkable past history, does not take any regular medications other than paracetamol for the occasional headache, and has no allergies. Dan is a 30-packet-per-year smoker and likes to meet his mates at his local pub every Friday for a couple of drinks.
You and your buddy nurse have just received handover from the night shift nurse and note that the surgical registrar has requested hourly neurovascular observations be performed on Mr Smith until he undergoes surgical repair.
Question 1a (approx. 80 words)
Discuss how you would perform neurovascular observations on Mr Smith and outline how the nurse would recognise a compromise in the neurovascular status of Mr Smith.
Dan is now Day 1 post surgery and is tolerating diet and fluids well. His pain has been well controlled via a Patient Controlled Analgesia (PCA) which was taken down this morning and he has been charted for oral analgesia in its place. At 1000, Dan buzzes his call bell and asks for assistance to have a wash as his partner will be visiting soon and he wants to look presentable. As a MNSc student, you understand that the extent with which the nurse may need to help with personal hygiene will depend on the patient’s physical abilities, health problems and the degree of hygiene required, however, there are a number of governing guidelines that nurses should follow when providing hygiene to their patients.
Question 1b (approx. 150 words)
Outline six (6) of these guidelines and discuss how you would implement them in your nursing care while assisting Dan with personal hygiene.
In preparation for assisting Dan with personal hygiene, you question Dan about his level of pain, as you understand that movement may cause additional pain. Dan reports a current numerical pain score of 7/10 and indicates he would like to take some additional pain relief prior to having a wash. You discuss this with your buddy nurse and together you agree on the most appropriate medication to administer.
Question 1c. (approx. 70 words)
Using the chart below choose the most appropriate medication to be administered. Provide a rationale for the use of this medication.
Question 1d. (approx. 10 words)
Calculate how many tablets you would need to administer to Dan.
Question 1e. (approx. 30 words)
Under what name and classification should a medication be prescribed by the physician? Provide a rationale for your answer
Question 1f. (approx. 70 words)
Propose when it would be safe to discharge Dan home
Question 1g. (approx. 50 words)
Identify which referrals you would make to ensure that Dan is safely discharged and has the assistance he needs.
CASE STUDY TWO: Ms Eliza Evans
Ms Eliza Evans is a 78-year-old woman who has just been admitted to University Hospital Ward 1B. Ms Evans is alert and orientated with a Glasgow Coma Scale (GCS) of 15. Despite having a slight visual impairment for which she needs glasses, Ms Evans lives by herself in her own home. Ms Evans has been having 3rd daily dressings to a laceration on her right anterior tibia which was caused by a fall in her house one week ago.
Fiona, the community nurse who reviewed Ms Evans, called the ambulance due to vertigo, urinary frequency, fever and observed that Ms Evans appeared to be uncharacteristically confused to the day and date. Fiona also noted significant weight loss.
You are on an afternoon shift in Ward 1B and are waiting for Ms Evans to be admitted to the ward via ED. The morning shift nurse advises you of the following:
Ms Evans has been admitted to hospital for investigation of weight loss, urinary frequency and vertigo.
Her past history includes: Chronic Heart Failure (CCF), Hypertension (HT) Tinnitus, Glaucoma, Anxiety, Depression, Urinary Tract Infection (UTI) and Rheumatoid Arthritis (RA).
Ms Evans is on several medications, including Atenolol 50mg, Aspirin 100mg, Frusemide 40mg BD and Alprazolam 1mg BD. She has an allergy to shellfish.
Ms Evans normally mobilized with the aid of a walking frame, however, she would not let the ambulance officers bring it with her to hospital, stating “the last time I was in hospital the lady in the next bed stole my walker and I had to buy a new one!”
Question 2a. (approx. 40 words)
Identify six (6) patient characteristics outlined in the profile above that would place Ms Evans at an increased risk of having a fall whilst in hospital.
Question 2b. (approx. 75 words)
Outline four (4) nursing interventions that would assist in reducing the risk of Ms Evans a fall whilst in hospital.
Provide a rationale for each intervention.
Question 2c. (approx. 250 words)
Discuss how you would perform an assessment of conscious state in this case.
Question 2d. (approx. 10 words)
Using the Neurological Observation conscious state form in appendix A at the end of this exam paper, correctly fill out the following GCS results of your assessment of Ms Evans.
• Eyes open to speech
• Is confused to time and day but is aware of location
• Able to follow commands
• Pupils are equal and reactive and measure 4mm
• You feel a mild weakness in her left arm, normal strength right arm
• Equal strength in both lower limbs
• Vital signs: Temp 365C, PR 89 regular, RR 16 no accessory muscles being used, Sp02 96% RA, BP 190/94
• Is complaining a severe headache and has reported 8/10 pain on a numerical pain score
On completing your assessment and reviewing the observations as well as the Medication Administration Record (MAR) you note new upper limb weakness, an elevated blood pressure and a pain score of 8/10. You note that she has had her antihypertensive this morning however she has been nauseous. When questioned Ms Evans indicates that she vomited into the toilet after breakfast. You discuss your concern with your buddy nurse who suggests making a RAPID call to Ms Evans doctor and request a review of the patient.
Question 2e. (approx. 300 words)
Using the ISBAR framework outline how you would report to Ms Evans doctor to request a review.
Question 2f. (approx.100 words)
Provide a summary the correct way to receive a phone order for a medication.
Question 2g. (approx. 10 words)
Using the MAR below correctly fill out a phone order for Atenolol 25mg.
Question 2h. (approx. 10 words)
Calculate how many tablets you would need to administer to Ms Evans with a stock strength of 50mg per tablet. Ensure that you include your calculation in your answer.
Question 2i. (approx. 80 words)
Using the MAR below list elements of validity in ensuring safe administration of medications to Ms Evans.
CASE STUDY THREE: Mrs Lucy Edwards
Mrs Edwards is a 70-year-old lady who has been admitted to University Hospital Ward 1B University Hospital after a mechanical fall at home. She has been diagnosed with a fracture of the right neck of femur.
Prior to this accident, Mrs Edwards was fit and well. She lives with her husband of 50 years and together they enjoy playing lawn bowls four times a week at their local club. She has 4 children and 6 grandchildren, all living within a 10-minute drive.
She has a history of Hypertension (HT) which is treated with Hydralazine 50mg q.i.d and Indapamide hemihydrate 2.5mg daily. Mrs Edwards has no known allergies (NKA).
Her clinical course has been uncomplicated and includes undergoing a R) Total Hip Replacement (THR).
It is now day four after Mrs Edwards’ surgery, she can mobilise slowly around the ward with the assistance of a gutter frame and one (1) nurse. However, Mrs Edwards does this reluctantly, as she is still experiencing a lot of pain.
Question 3a. (approx.200 words).
Using this information above, and using a COLDSPAA framework, provide a summary of how you would ascertain Mrs Edwards’ level of pain.
Question 3b. (approx. 50 words)
It is now 1230 and after performing a comprehensive pain assessment, Mrs Edwards indicates to you on a numerical pain scale a pain score of 4/10. Using the medication chart below, identify the most appropriate course of action to manage Mrs Edwards’ level of pain. Provide justification for your choice.
Question 3c. (approx. 150 words)
Using the MAR below identify the 10 rights of medication administration and discuss how you would ensure the safe administration of medications to your patient within the frame of your existing scope of practice.
Question 3d. (approx. 50 words)
After 15-30 minutes, you visit Mrs Edwards to assess if her pain medication has worked. However, Mrs Edwards now appears in greater pain. When asked, she evaluates her pain at 9/10. Discuss what your next nursing intervention would be in this situation.
Question 3e. (approx. 75 words)
It is now 0800 and your buddy nurse has asked you to review Mrs Edwards MAR below and identify any medications due for 0800.
Question 3f. (approx. 50 words)
What assessments should you perform prior to administering Mr Edwards mane medications? Provide justification for your decision.
Question 3g. (approx. 30 words)
Calculate many tablets should be given of each medication using the following stock strength. Ensure that you include your calculations in your answer.
• Hyralazine - stock strength 25mg
• Indapamide hemihydrate - stock strength 2.5mg
Over the next two days, Mrs Edwards has noticed that she feels bloated and has not used her bowels for six (6) days. She tells you that she has been straining upon defecation and has only passed a small hard dry stool (1 on Bristol chart).
Question 3h. (approx. 200 word)
Being aware of this information, propose what assessments and which nursing interventions would be appropriate in this case.
Question 3i. (approx. 100 words)
What impact might her age have on Mrs Edwards’ bowel function?
Question 3j. (approx. 10 words)
Using the information above, and using a NANDA framework, develop one (1) actual nursing diagnosis related to Mrs Edwards’ constipation.
CASE STUDY FOUR: Mr Graham
Mr Graham is 75-year-old male and has been admitted to University Hospital Ward 1B University Hospital for Congestive Heart Failure (CCF).
He has a past history of CCF, Hypertension (HT), diabetes mellitus and he is obese. He has a family history of CCF
Regular medications include: Metformin 750mg BD, Ramipril 10mg mane, Frusemide 40mg BD. Mr Graham has no known allergies (NKA)
Socially, Mr Graham is divorced and lives alone, though his daughter visits weekly. He is estranged from his 2 sons. Mr Graham is a 50-pack-a-year smoker and is a heavy drinker.
On receiving handover from the ED nurse you note that Mr Graham is VRE+ (Vancomycin-resistant Enterococci positive) and requires isolation. Your buddy nurse asks you to prepare Mr Graham’s room prior to his arrival.
Question 4a. (approx. 150 words)
Discuss four (4) clinical scenarios when the nurse must implement standard precautions and don PPE. In your answer identify the type of precautions you should initiate for Mr Graham and explain what PPE a nurse would apply when entering Mr Graham’s room. Provide a rationale for your choice.
On admission, you perform an assessment including vital signs. You note the following:
• Weight gain of 3kg in the past month
• Blood cholesterol 320mg/ml
• High-density lipoprotein (HLD) 28mg/dl
• Blood pressure 186/116
• Radial Pulse Rate 76bpm (you believe it to be irregular)
• Respiratory Rate 21 and obvious use of accessory muscles
• Sp02 95% RA
• Oral temp 363 C
• BGL 8.9mmol/L
• Diminished visual acuity
• Decreased bladder tone
• Weakness and dizziness
• Glasgow Coma Scale (GCS) score of 12 (E3, V4, M5)
When reporting these findings to your buddy nurse, she asks you to perform an apical pulse assessment to confirm the suspected irregular heart rate (HR).
Question 4b. (approx. 300 words)
Identify the following traditional areas of cardiac auscultation on the the picture below and explain which part of the heart you are listening to when auscultating at each of those anatomical regions. Explain the process an RN shoud undertake when auscultating the apical pulse and explain why is it important to auscultate the heart when suspecting an irregular radial pulse.
During your AM shift, Mr Graham’s condition deteriorated, and he was admitted to CCU at University Hospital for cardiac monitoring. After 4 days, he returns to Ward 1B. You perform another admission assessment and note the following:
• Glasgow Coma Scale (GCS) score of 15 (E4,V5,M6)
• Blood pressure 130/90
• Radial Pulse Rate 76bpm regular
• Respiratory Rate 16bpm
• Sp02 97% RA
• Oral temp 363C
• BGL 5.3mmol/L
Mr Graham still describes
• Diminished visual acuity
• Weakness and dizziness
Question 4c. (approx. 60 words)
Using the information above and using a NANDA framework, develop one (1) actual nursing diagnosis related to Mr Graham’s current situation.
Mr Graham has just pressed his call bell and told you that he feels nauseous and has asked for you to administer something to “make it feel better”. You speak with your buddy nurse and together you review Mr Graham’s MAR and note that he has a prescription for antiemetic therapy on the MAR.
Question 4d. (approx. 50 words)
Using the MAR below, identify the components of a valid order and propose whether you can administer medication as it is currently prescribed. Propose a resolution to the situation and provide rationale for your solution.
CASE STUDY 5: Ms Olive Brown
Olive Brown is a 4-year-old girl who has been admitted to University Hospital Ward 1B with a chest infection.
She is accompanied by her mum and grandmother and a younger sibling.
Olive’s mum informs you that she is normally a bright and curious child who does not stop asking questions. However, over the last 3 days, she has become increasingly lethargic and is not interested in her normal activities. Olive’s mum indicates to you that she has lost her appetite and it has been difficult to get Olive to drink anything.
Olive has no past history but is allergic to peanuts.
Your buddy nurse asks you to perform a set of vital signs, however, before entering Olive’s bedspace you remember that the hands of health care workers are the most common way that bacteria-causing infections are transmitted between patients in hospitals.
Question 5a. (approx. 150 words)
Outline the five (5) moments of hand hygiene and discuss the need for each moment.
After completing hand hygiene, you perform a set of vital signs and note the following:
• Blood pressure 95/60
• Radial Pulse Rate 153bpm regular
• Respiratory Rate 29bpm
• Sp02 94% RA
• Oral temp 389C
• She appears flushed and is hot to touch
Question 5b. (approx. 50 words)
Using the track and trigger vital signs form at the back of this exam, correctly document these vital signs. Based on your assessment, what should your next action be?
While you are performing Olive’s vital signs, her Grandmother Jenny asks why you are using a tympanic thermometer, stating, “I’ve always used a thermometer that goes under the tongue, I’m sure what you’re using isn’t as accurate.”
Question 5c. (approx.70 words)
To educate Jenny on the use of tympanic thermometers, you engage in a discussion on the advantages and disadvantages of tympanic thermometers. List six (6) advantages and six (6) disadvantages of the tympanic temperature measurement that you might highlight when speaking with Jenny.
Olive’s condition remains stable and she appears to be more engaged and has even managed to eat and drink something for dinner. However, Olive now appears to be developing a productive cough and you notice a respiratory wheeze. You speak with your buddy nurse regarding this change, she asks you what you think your next step should be. You reply that prior to escalating to Olive’s doctor, you would like to perform a respiratory assessment.
Question 5d. (approx. 300 words)
Discuss how would you perform a focused respiratory assessment in this case. Provide justification for each element and performing a respitratory assessment.
Question 5e. (approx. 10 words)
Olive has now been prescribed 360mg Amoxycillin oral suspension twice a day for a chest infection. Using the diagram below calculate many mls of Amoxycillin you will administer.
End of Examination
Appendix One: Neurological Observation Conscious State Form
Appendix Two: Track and Trigger observations chart