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Evolve Case Study: Medical/Surgical - Brain Attack (Stroke)

Uploaded: 2 years ago
Contributor: imjustme
Category: Medicine
Type: Other
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Filename:   Brain Attack (stroke).docx (215.2 kB)
Page Count: 19
Credit Cost: 1
Views: 180
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Description
Meet the Client: Nancy Jackson

Nancy Jackson, a 72-year-old Caucasian female, is brought to the Emergency Department at St. John's Medical Center, a Catholic facility, by her daughter, Gail. Mrs. Jackson, who asks the staff to call her Nancy, is complaining of right-sided weakness, a severe headache, and just not feeling well for the last 24 hours.
Transcript
Clinical Manifestations The emergency room nurse is completing the admission assessment. Nancy is alert, but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened.   1. What additional clinical manifestation does the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? A) A carotid bruit. Feedback: CORRECT The carotid artery (artery to the brain) is narrowed in clients with a brain attack. A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow.    B) A hypotensive blood pressure. Feedback: INCORRECT Usually the client's blood pressure is hypertensive. C) Hyperreflexic deep tendon reflexes. Feedback: INCORRECT Initially, flaccid paralysis occurs, resulting in hyporeflexic deep tendon reflexes. D) Decreased bowel sounds. Feedback: INCORRECT The bowel sounds are not indicative of a brain attack. Points Earned: 0.0/1.0 Correct Answer(s): A The emergency room physician has completed an assessment. Gail is sitting at the bedside while the emergency room nurse continues to assess Nancy every 15 minutes. 2. Which assessment finding warrants immediate intervention by the nurse? A) Nancy’s Glasgow Coma Scale (GCS) score increases. Feedback: INCORRECT A decreasing, not increasing, GCS indicates worsening of the client's condition. This finding does not warrant immediate intervention by the nurse. B) Nancy’s bilateral grip strength is unequal. Feedback: INCORRECT This is an expected finding in a client with a brain attack. This finding does not warrant immediate intervention by the nurse. C) Nancy only responds to painful stimuli. Feedback: CORRECT Nancy was alert upon admission and now only responds to a painful stimulus, which indicates a worsening condition. This decrease in responsiveness warrants immediate intervention by the nurse. D) Nancy has a negative Babinski's reflex bilaterally. Feedback: INCORRECT A negative Babinski's reflex is expected in a client with an intact brain stem. This finding does not warrant immediate intervention by the nurse. Points Earned: 1.0/1.0 Correct Answer(s): C Due to her deteriorating condition, Nancy is immediately referred to the neurologist. The emergency room nurse realizes that Nancy has probably suffered a left-sided brain attack. 3. Which clinical manifestation further supports this assessment? A) Visual field deficit on the left side. Feedback: INCORRECT These deficits usually occur with right-sided brain attack. B) Spatial-perceptual deficits. Feedback: INCORRECT These deficits usually occur with right-sided brain attack. C) Paresthesia of the left side. Feedback: INCORRECT These deficits usually occur with right-sided brain attack. D) Global aphasia. Feedback: CORRECT Global aphasia refers to difficulty speaking, listening, and understanding, as well as difficulty reading and writing. Symptoms vary from person to person. Aphasia may occur secondary to any brain injury involving the left hemisphere.   Points Earned: 0.0/1.0 Correct Answer(s): D Diagnostic Tests The neurologist writes a diagnosis of, "Suspected brain attack" and prescribes a noncontrast computed tomography (CT) scan STAT. 4. What nursing intervention should the nurse implement when preparing Nancy for this procedure? A) Determine if the client has any allergies to iodine. Feedback: INCORRECT This information is important if contrast dye is being used for the CT scan. B) Explain that the client will not be able to move her head throughout the CT scan. Feedback: CORRECT Because head motion will distort the images, Nancy will have to remain still throughout the procedure.  C) Premedicate the client to decrease pain prior to having the procedure. Feedback: INCORRECT CT scanning is a noninvasive and painless procedure. D) Provide an explanation of relaxation exercises prior to the procedure. Feedback: INCORRECT While this is a worthwhile intervention to decrease anxiety, there is another intervention of higher priority. Points Earned: 0.0/1.0 Correct Answer(s): B The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT. 5. Which data warrants immediate intervention by the nurse concerning this diagnostic test? A) Elevated blood pressure. Feedback: INCORRECT This would not affect the MRI. B) Allergy to shell fish. Feedback: INCORRECT This would not affect the MRI. C) Right hip replacement. Feedback: CORRECT The magnetic field generated by the MRI is so strong that metal-containing items are strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during the procedure. D) History of atrial fibrillation. Feedback: INCORRECT This would not affect the MRI. Points Earned: 0.0/1.0 Correct Answer(s): C Therapeutic Communication Nancy is transferred to the Intermediate Care Unit after the MRI is completed. Gail is sitting by her mother's bed. The nurse asks Gail if there is anyone that can be called so that she won't be alone. She informs the nurse that she is an only child and her father died years ago. Gail states, "I don't understand what a brain attack is. The healthcare provider told me my mother is in serious condition and they are going to run several tests. I just don't know what is going on. What happened to my mother?" 6. What is the best response by the nurse? A) "I am sorry, but according to the Health Insurance Portability and Accounting Act (HIPAA), I cannot give you any information." Feedback: INCORRECT The nurse can discuss what a diagnosis means. Nancy is unable to make decisions, so the next of kin, her daughter, Gail, needs sufficient information to make informed decisions. B) "Your mother has had a stroke, and the blood supply to the brain has been blocked." Feedback: CORRECT The nurse has the knowledge, and the responsibility, to explain Nancy's condition to Gail. C) "How do you feel about what the healthcare provider said?" Feedback: INCORRECT The nurse should give facts first, and then address her feelings after the information is provided. D) "I will call the healthcare provider so he/she can talk to you about your mother's serious condition." Feedback: INCORRECT This is passing the buck. The nurse can, and should, address Gail's lack of knowledge. Points Earned: 1.0/1.0 Correct Answer(s): B Gail starts to cry and states, "Mom was just fine last week when we went out to eat and to a show. I love my mom so much, and I am so scared. She is all I have." 7. How should the nurse respond? A) "I am sure everything will be all right." Feedback: INCORRECT This response provides false reassurance and does not allow Gail to share her feelings. B) "I know this is scary for you. Would you like to sit and talk?" Feedback: CORRECT This therapeutic response provides acknowledgment of Gails fears, and the nurse offers to take time to discuss the situation.  C) "I will notify the chaplain to come and sit with you so you won't be alone." Feedback: INCORRECT This is passing the buck. The nurse should address Gail's feelings. D) "I am sure your mother knows you are here. Just keep talking to her." Feedback: INCORRECT This may be therapeutic for Nancy, but it is not therapeutic for Gail. Points Earned: 1.0/1.0 Correct Answer(s): B Nursing Interventions The neurologist diagnoses an ischemic left-sided brain attack (stroke). The neurologist determines that Nancy is not a candidate for tissue plasminogen activator (tPA). Enoxaparin (Lovenox) is prescribed. 1 mg/kg subcutaneously every 12 hours. 8. What intervention should the nurse include in the plan of care? A) Monitor Nancy's INR daily. Feedback: INCORRECT The nurse should monitor the PTT level during heparin therapy. INR is monitored for warfarin (Coumadin) therapy. B) Assess Nancy's neurological status every shift. Feedback: INCORRECT The neurological status must be monitored more frequently than every 8 or 12 hours as indicated by the shift change. C) Evaluate Nancy's platelet levels daily. Feedback: INCORRECT Anticoagulants inhibit thrombin formation and do not usually affect platelet levels. D) Keep the head of the bed elevated. Feedback: CORRECT Maintaining a patent airway is essential to support oxygenation and cerebral perfusion. Elevating the head of the bed 30 degrees aids in preventing the tongue from falling backward and obstructing the airway. Points Earned: 0.0/1.0 Correct Answer(s): D The nurse is monitoring Nancy's condition closely. 9. Which finding would require immediate intervention by the nurse? A) Nancy's cardiac output is less than 4 L/min. Feedback: CORRECT The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8 L/min. B) Nancy's pulse oximeter reading is greater than 95%. Feedback: INCORRECT A pulse oximeter reading of 95% indicates adequate oxygenation to the peripheral tissues. C) Nancy's serum potassium level is 3.9 mEq/L. Feedback: INCORRECT This potassium level is within normal limits (3.5-5.5 mEq/L). D) Nancy's telemetry shows normal sinus rhythm with occasional premature ventricular contractions. Feedback: INCORRECT Occasional PVCs do not require immediate intervention. Points Earned: 0.0/1.0 Correct Answer(s): A Nancy's cardiac output, SaO2, potassium level, and telemetry readings are within normal limits for her age. As the nurse assesses Nancy, Gail asks, "Why isn't my mother a candidate for thrombolytic therapy?" 10. How should the nurse respond? A) "I think that is something you should discuss with your mother’s healthcare provider." Feedback: INCORRECT The nurse has the knowledge and ability to answer the question. B) "She is not a candidate because she waited too long before seeking help." Feedback: CORRECT Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior to admission. Nancy had symptoms for 24 hours before being brought to the medical center.  C) "tPA is usually not administered to anyone older than 65 years." Feedback: INCORRECT This is false information. There are certain criteria when thrombolytic therapy would not be administered, but age is not one of them. D) "Since your mother was alert on admission, she is not a candidate to receive this medication." Feedback: INCORRECT This is false information. There are certain criteria when thrombolytic therapy would not be administered, but being alert is not one of them. Points Earned: 1.0/1.0 Correct Answer(s): B Nursing Diagnosis Nancy spends three days in the Intermediate Care Unit. Once stabilized, she is transferred to a 40-bed medical unit. Nancy has right-sided paralysis, facial drooping, global aphasia, and dysphagia. She has a 20-gauge saline lock in the right forearm and an 18 French indwelling urinary (Foley) catheter. Other than bedrest, Nancy's healthcare provider prescribes sitting up in a chair four times a day. 11. Which nursing diagnosis has the highest priority? A) Impaired physical mobility. Feedback: INCORRECT Although Nancy has right-sided paralysis, that is not the highest priority. B) Self-care deficit. Feedback: INCORRECT Although Nancy has facial drooping, that is not the highest priority. C) Impaired social interaction. Feedback: INCORRECT Although Nancy has difficulty communicating due to the aphasia, that is not the highest priority. D) Impaired swallowing. Feedback: CORRECT According to Maslow's Hierarchy of Needs, physiological needs should be addressed first. Therefore, Nancy's dysphagia is the highest priority nursing diagnosis. Points Earned: 1.0/1.0 Correct Answer(s): D Because Nancy is right-handed and is having difficulty performing activities of daily living with the left arm, the nurse also includes the nursing diagnosis "self-care deficit" in the care plan. 12. Which intervention would the nurse implement to address this nursing diagnosis? A) Use narrow grip utensils to accommodate a weak grasp. Feedback: INCORRECT Wide-grip utensils should be used to accommodate a weak grasp. B) Utilize plate guards when Nancy is eating. Feedback: CORRECT Plate guards prevent food from being pushed off the plate. Using plate guards and other assistive devices will encourage independence in a client with a self-care deficit.  C) Discourage Nancy from using assistive devices. Feedback: INCORRECT Assistive devices can be of great benefit and encourage independence. D) Recommend a regular type toilet seat with grab hand bars. Feedback: INCORRECT This intervention discourages client independence. Points Earned: 1.0/1.0 Correct Answer(s): B Teaching/Health Promotion Gail asks the nurse, "Why did Mom have this stroke? Do you think that I might have one since she had one?" The nurse and Gail discuss risk factors for a brain attack and ways to decrease the risks. 13. Which condition is considered a non-modifiable risk factor for a brain attack? A) High cholesterol levels. Feedback: INCORRECT This is a modifiable risk factor. B) Obesity. Feedback: INCORRECT This is a modifiable risk factor. C) History of atrial fibrillation. Feedback: INCORRECT This is a modifiable risk factor. D) Advanced age. Feedback: CORRECT People over age 55 are a high-risk group for a brain attack because the incidence of stroke more than doubles in each successive decade of life. Non-modifiable means the client cannot do anything to change the risk factor.  Points Earned: 1.0/1.0 Correct Answer(s): D Gail tells the nurse she is going to go outside to smoke a cigarette and will only be gone for a few minutes. 14. Which statement is warranted in this situation? A) "I should let you know that smoking is a strong risk factor for a brain attack." Feedback: CORRECT The nurse should teach Gail that smoking is a modifiable risk factor that could prevent her from having a stroke. Smoking increases the risk for hypertension which is a risk factor for a stroke. B) "That is just fine. I will be here taking care of your mother." Feedback: INCORRECT This response enables, and possibly encourages Gail to continue smoking. C) "Make sure you smoke in the smoking area only. The hospital has strict rules." Feedback: INCORRECT This response enables, and possibly encourages Gail to continue smoking. D) "How long have you been smoking?" Feedback: INCORRECT While this is useful information, it does not address Gail's decision to go out and smoke. Points Earned: 1.0/1.0 Correct Answer(s): A Nursing Interventions Nancy is experiencing homonymous hemianopsia as the result of her brain attack. 15. Which nursing intervention would the nurse implement to address this condition? A) Turn Nancy every two hours and perform active range of motion exercises. Feedback: INCORRECT That intervention would address the client’s risk for immobility due to paralysis. B) Place the objects Nancy needs for activities of daily living on the left side of the table. Feedback: CORRECT Homonymous hemianopsia is loss of the visual field on the same side as the paralyzed side. This results in the client neglecting that side of the body, so it is beneficial to place objects on that side. Nancy had a left-hemisphere brain attack so her right side is the weak side.  C) Speak slowly and clearly to assist Nancy in forming sounds to words. Feedback: INCORRECT That intervention would address the client's verbal deficits due to aphasia. D) Request that the dietary department thicken all liquids on Nancy's meal and snack trays. Feedback: INCORRECT This would address dysphagia. Points Earned: 1.0/1.0 Correct Answer(s): B Nancy is experiencing pain in her right shoulder. The nurse is aware that up to 70% of clients with a brain attack experience severe pain in the shoulder that prevents them from learning new skills. Shoulder function helps clients achieve balance, perform transfer skills, and participate in self-care activities. 16. Which intervention should the nurse implement when addressing this condition? A) Move Nancy by lifting with the affected shoulder. Feedback: INCORRECT The nurse should never lift or pull the client by the affected shoulder. B) Remind Nancy to perform active range of motion exercises daily. Feedback: INCORRECT Active ROM exercises should be performed at least every 4 hours. Once a day is not enough to prevent contractures. C) Assist Nancy to keep the affected arm in a dependent position as much as possible. Feedback: INCORRECT The affected arm should be elevated to prevent dependent edema in the hand. D) Instruct Nancy to clasp the right hand with the left hand and raise both hands above the head. Feedback: CORRECT This exercise helps prevent "frozen shoulder" and will aid the nurse when moving or positioning the client. Points Earned: 1.0/1.0 Correct Answer(s): D Gail tells the nurse, "One of the people in the waiting room was telling me about an operation that her mother had to prevent a stroke. Do you know anything about that?" 17. How should the nurse respond? A) "There is currently no surgery that can help prevent a stroke." Feedback: INCORRECT This is not correct information. B) "That procedure is only done with small strokes, not like the one your Mom had." Feedback: CORRECT This surgery is indicated for clients with symptoms of transient ischemic attack (TIA), or mild stroke, found to be due to severe carotid artery stenosis or moderate stenosis with other significant risk factors.  C) "Yes, it is a carotid endarterectomy, and your mother may be able to have one." Feedback: INCORRECT This is not correct information. D) "I am sure your healthcare provider will discuss that with you at a later date." Feedback: INCORRECT The nurse has the knowledge and responsibility to answer this question, even if Gail chooses to ask Nancy's healthcare provider about it later. Points Earned: 0.0/1.0 Correct Answer(s): B Management The nurse on the day shift is caring for Nancy and four other medical clients. There are two unlicensed assistive personnel (UAPs) on the unit assisting with the client care. 18. Which nursing care task should the nurse delegate to the UAP? A) Assist Nancy to eat her breakfast. Feedback: INCORRECT Since Nancy has dysphagia, the nurse should not delegate this high-risk task to the UAP. B) Flush Nancy's saline lock with 2 ml of normal saline. Feedback: INCORRECT IV fluids are medications. Medication administration cannot be delegated to the UAP. C) Use a walker to help Nancy ambulate down the hall. Feedback: INCORRECT Nancy has right-sided paralysis and should be taught to walk by the physical therapist. D) Give Nancy a bed bath and change the bed linens. Feedback: CORRECT The UAP can assist Nancy with bathing and then change the bed linens. This task does not require professional judgment and expertise. Points Earned: 1.0/1.0 Correct Answer(s): D A physical therapist (PT) places a gait belt on Nancy and is assisting her with ambulation from the bed to the chair. As she gets up out of the bed, she reports being dizzy and begins to fall. The PT carefully allows her to fall back to the bed and notifies the primary nurse. 19. Which written documentation should the nurse put in the client's record? A) Client experienced orthostatic hypotension when getting out of bed. Feedback: INCORRECT The nurse is making an assumption that the dizziness was caused by orthostatic hypotension. B) PT reported client complained of dizziness when getting out of bed, and gait belt was used to allow client to fall back onto the bed. Feedback: CORRECT This documentation provides the factual data of the events that occurred. C) PT notified the primary nurse that the client could not ambulate at this time because of dizziness. Feedback: INCORRECT Not all the pertinent facts are included in this documentation. D) Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance report completed. Feedback: INCORRECT A variance report should never be documented in the client's record. Points Earned: 1.0/1.0 Correct Answer(s): B Nursing Care in the Rehabilitation Unit Nancy is progressing physically and is transferred to the rehabilitation unit. She continues to have total right-sided paralysis, facial drooping, global aphasia, and dysphagia. She has an indwelling urinary (Foley) catheter. She is scheduled for 3 hours of therapy daily. The rehabilitation team meets to review Nancy's plan of care. 20. Which intervention should the nurse implement to prevent joint deformities? A) Place Nancy in a prone position for 15 minutes at least four times a day. Feedback: CORRECT This helps to promote hyperextension of the hip joints, which helps prevent knee and hip flexion contractures.  B) Position the fingers so that they are totally flexed in a slight pronation position. Feedback: INCORRECT The fingers should be barely flexed and placed in supination (palm faces upward), the normal anatomical position. C) Place the elbow lower than the shoulder and the wrist lower than the elbow on the affected side. Feedback: INCORRECT The elbow should be higher than the shoulder and the wrist higher than the elbow to prevent edema and possible joint fibrosis that will occur and limit ROM if Nancy regains use of the arm. D) Apply splints to the arms and legs during the day but remove at night. Feedback: INCORRECT Because flexor muscles are stronger than extensor muscles, posterior splints should be applied at night to prevent flexion and maintain correct positioning during sleep. Points Earned: 0.0/1.0 Correct Answer(s): A Nancy has difficulty communicating with the rehabilitation team and her daughter. Gail is very upset that her mother can't communicate and tells the nurse that Nancy has always been an eloquent speaker. Gail is helping her mother by answering questions for her and trying to anticipate what she wants. 21. What action should the nurse implement to address this situation? A) Praise Gail for trying to anticipate her mother's needs. Feedback: INCORRECT Although Gail should be encouraged and praised for helping her mother, the nurse should discourage this behavior. Nancy should attempt to do as much for herself as possible. B) Inform Gail that Nancy will start speech therapy soon. Feedback: INCORRECT While this may be true, the nurse should address the situation. C) Discuss how to use a communication board with both Nancy and her daughter. Feedback: CORRECT A communication board has pictures of common needs and phrases that helps with communication. The nurse can easily teach this effective technique to Nancy and Gail.  D) Explain that Nancy's speech will become clearer as she gets better. Feedback: INCORRECT Nancy's speech may become better, but it may not. This is false reassurance. Points Earned: 1.0/1.0 Correct Answer(s): C 22. Which rehabilitation team member is responsible for evaluating Nancy's dysphagia? A) The rehabilitation physician. Feedback: INCORRECT The physician does not evaluate dysphagia. B) The speech therapist. Feedback: CORRECT The speech therapist evaluates the client's gag reflex and ability to swallow, then makes recommendations regarding feeding techniques and diet. C) The case manager. Feedback: INCORRECT The case manager is usually a registered nurse that coordinates the client's care with the multidisciplinary team members. D) The occupational therapist. Feedback: INCORRECT The occupational therapist helps clients achieve independence in activities of daily living. Points Earned: 1.0/1.0 Correct Answer(s): B Nutritional Concerns Because Nancy is unable to swallow effectively, not only is she at risk for choking, but she is no longer able to meet her nutritional needs and has lost 10 lbs. A gastrostomy tube is prescribed so that tube feedings can be administered. 23. Which intervention should the nurse implement while Nancy is receiving tube feedings? A) Keep the head of the bed at a 10-degree angle during the feeding. Feedback: INCORRECT The head of the bed should be elevated at least 30 degrees to prevent aspiration. B) Stop the tube feeding if the residual is greater than 10 ml. Feedback: INCORRECT The nurse should aspirate Nancy every 4 hours to ensure that the feedings are being digested. Usually a residual amount greater than 60 ml indicates that the next feeding should be held. C) Deflate the 20 ml gastrostomy balloon between feedings. Feedback: INCORRECT The balloon should be inflated to ensure that the feeding tube remains in place in the stomach. D) Cleanse the gastrostomy insertion site with soap and water daily. Feedback: CORRECT Because the skin around the gastrostomy tube may become irritated from the enzymatic action of gastric juices that leak around the tube, the stoma should be cleansed daily.  Points Earned: 1.0/1.0 Correct Answer(s): D The healthcare provider orders one 240 ml can of liquid nourishment diluted with one can of water to be infused over 8 hours. The feeding will be administered through an infusion pump which infuses in ml/hr. 24. At what rate would the nurse set the infusion pump? A) 40 ml/hr. Feedback: INCORRECT Remember the formula for ml per hour. B) 60 ml/hr. Feedback: CORRECT The nurse must add 240 ml (fluid) plus 240 ml (water), which equals 480 ml. Divide 480 ml by 8 hours. The pump should be set at 60 ml/hr. C) 100 ml/hr. Feedback: INCORRECT Remember the formula for ml per hour. D) 240 ml/hr. Feedback: INCORRECT Remember the formula for ml per hour. Points Earned: 1.0/1.0 Correct Answer(s): B Legal Issues Nancy appears depressed and Gail reports that her mother seems to have lost all hope. Gail reminds the staff that her mother has a Living Will and a Do Not Resuscitate order. Gail has a Durable Power of Attorney for Health Care that was signed over two years ago. A week later, Gail is sitting at the bedside when Nancy starts to gasp for air. Gail yells for the nurse. When the nurse arrives, Nancy is not breathing. The nurse assesses Nancy's apical pulse, but cannot hear anything. 25. Which intervention should the nurse implement? A) Call a code immediately and reposition Nancy's airway. Feedback: INCORRECT This is not the correct action to take in this situation. B) Continue to stay at Nancy's bedside and hold Gail's hand. Feedback: CORRECT The client has a DNR order. Therefore, no action should be taken. Providing support to the daughter as her mother dies is the best nursing action in this situation.  C) Provide Nancy with 2 rescue breaths and assess the carotid pulse. Feedback: INCORRECT This is not the correct action in this situation. D) Turn Nancy to the left lateral position and assess the apical heart rate. Feedback: INCORRECT This is not the correct action in this situation. Points Earned: 1.0/1.0 Correct Answer(s): B The telephone at Nancy's bedside starts ringing. The nurse answers the phone. The caller is one of Nancy's neighbors, wanting to know how she is doing. 26. How should the nurse respond? A) "I am so sorry, but Nancy just passed away." Feedback: INCORRECT This violates the client's right to confidentiality. B) "I will have Nancy's daughter call you at a later time." Feedback: INCORRECT The nurse should not speak for Nancy's daughter. Gail may not want to call people back at this time. C) "I am sorry, but I am unable to give you any information." Feedback: CORRECT According to HIPAA, the client has a right to confidentiality. The nurse cannot give any information to someone that does not have a "need to know." D) "Let me have your number, I will call you back in a few minutes." Feedback: INCORRECT The nurse cannot give any information to Nancy's neighbor. Points Earned: 1.0/1.0 Correct Answer(s): C The nurse remains with Gail at Nancy's bedside. The healthcare provider is called and pronounces Nancy's death. Gail tells the nurse that Nancy wanted to be an organ donor. 27. Which action should the nurse implement? A) Obtain the necessary permits and notify the regional organ donor center. Feedback: INCORRECT This may be done, but another action should be implemented first. B) Explain that Nancy can only be a tissue donor, not an organ donor. Feedback: CORRECT Gail needs the correct information. The client must be on a ventilator and declared "brain dead" prior to donating body organs such as the heart, lungs, liver, and pancreas (oxygen is needed for viability). Corneas, skin, bones, and joints can be donated from deceased donors who suffer cardiac death. These tissues can be recovered up to 24 hours after death. In some circumstances, kidneys can also be obtained from non-ventilated deceased clients.   C) Explain that since Nancy was on heparin recently she cannot be a donor. Feedback: INCORRECT This is false information. Heparin does not affect the ability to donate organs or tissues. D) Remove all of Nancy's tubes and wash her body. Feedback: INCORRECT This is not the first action that the nurse should implement. Some facilities do not allow the nurse to remove the client's external tubes. Hospital policy/procedures should be followed. Points Earned: 0.0/1.0 Correct Answer(s): B Spiritual Considerations Nancy was a Roman Catholic, and although she received the sacrament known as "Anointing of the Sick" shortly after her brain attack, Gail wants her mother to receive Last Rites immediately. 28. Which action should the nurse implement? A) Notify the chaplain services immediately so the priest can come to the bedside. Feedback: CORRECT The nurse must advocate for the client and family, and should allow Nancy to have Last Rites.  B) Explain since Nancy has already received Anointing of the Sick, there is no need to call a priest. Feedback: INCORRECT The nurse must support the client's religious beliefs. C) Tell Nancy she must contact her own priest to come and bless Nancy. Feedback: INCORRECT The nurse can support the client's wishes and religious beliefs by actively assisting her while she is grieving. D) Discuss how long Gail thinks it will take for a priest to come to the hospital. Feedback: INCORRECT The nurse must support the client's religious beliefs and not worry about the length of time it would take to notify a priest. Points Earned: 1.0/1.0 Correct Answer(s): A Gail is crying quietly while sitting in Nancy's room. Gail tells the nurse that her mother wanted to be cremated and to have her ashes thrown over the lake where Nancy and her husband met over 50 years ago. Gail wants to bury her mother beside her father in the local cemetery and tells the nurse, "I just don't know what I should do." 29. How should the nurse respond? A) "You should do what your mother wanted." Feedback: INCORRECT This is advising and is not a therapeutic response. B) "I will contact the priest and ask him to talk to you about this." Feedback: INCORRECT This is "passing the buck" and is not a therapeutic response. C) "You seem really confused about what to do. Would you like to talk about it?" Feedback: CORRECT This is a therapeutic response and addresses Gail’s feelings. D) "Isn’t being cremated against Roman Catholic beliefs?" Feedback: INCORRECT It is not the nurse’s responsibility to question Roman Catholic beliefs. Points Earned: 1.0/1.0 Correct Answer(s): C The priest arrives and blesses Nancy. He also helps Gail reach a decision about whether to follow Nancy's wishes for cremation or bury Nancy next to her husband. Case Outcome Nancy's body is taken to the Tissue Donor Bank, and her wish to be a tissue donor is honored. Gail decides to respect her mother's wishes by having her body cremated and most of her ashes thrown over the lake. Gail decides to scatter a small amount of the ashes at her father's grave site. Gail thanks the entire nursing staff, as well as the rehabilitation staff for the wonderful nursing care her mother received. She tells the staff, "Knowing that my mother received such good care at the end makes her death a little easier to bear."

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