Nursing Education Capstone (C947)

Correct Answer

D. Myoglobin

Explanation

Myoglobin is the first cardiac enzyme to elevate following a myocardial infarction (MI), often appearing in the bloodstream within 1-2 hours of injury. It is a sensitive marker for muscle damage, including cardiac muscle, but it is not as specific to the heart as other markers like troponin. However, its early rise makes it useful for identifying the onset of damage. Myoglobin levels peak rapidly and then decrease, so it is typically used in combination with other tests for better diagnostic accuracy.

Why other options are wrong

A. Creatinine Kinase

Creatinine Kinase (CK) also rises after a myocardial infarction, but it typically appears slightly later than myoglobin. CK is a general marker of muscle injury, not specific to the heart, and can be elevated due to other causes, such as skeletal muscle injury, so it is less specific for MI than troponin.

B. CKMB

CKMB is a specific isoenzyme of creatine kinase that is more specific to the heart. However, its elevation is typically seen after myoglobin and creatine kinase. It becomes more useful for diagnosing MI once the initial phase has passed and other markers are still being evaluated.

C. Troponin

Troponin is the most specific marker for myocardial injury, but it takes longer to rise compared to myoglobin. Troponin levels begin to increase about 3-4 hours after myocardial injury and remain elevated for a longer period, making it a better marker for diagnosing and assessing the severity of an MI in the later stages.

Correct Answer

A.) Magnesium

B.) ALT, AST, and bilirubin

D.) Blood glucose

E.) Potassium

Explanation

Alcohol withdrawal can result in electrolyte imbalances and liver dysfunction. Magnesium and potassium levels should be monitored because alcohol withdrawal can lead to low magnesium (hypomagnesemia) and low potassium (hypokalemia), which can cause serious cardiovascular issues. Liver function tests (ALT, AST, and bilirubin) are essential because chronic alcohol use can lead to liver damage, and blood glucose should be monitored because alcohol withdrawal can result in hypoglycemia, especially in patients with poor nutritional status.

Why other options are wrong

C.) Lipid Panel

A lipid panel is not a priority test for a patient undergoing alcohol withdrawal. While chronic alcohol use can affect lipid levels, it is not directly related to the management or complications of alcohol withdrawal, making it a lower priority for this situation.

Correct Answer

B) A reaction to Disulfiram (Antabuse)

Explanation

The symptoms described—headache, tachycardia, flushed face, vomiting, diaphoresis, and shortness of breath—are consistent with a reaction to Disulfiram (Antabuse) when alcohol is consumed. Disulfiram is a medication used to help individuals with alcohol dependence maintain sobriety by causing unpleasant symptoms when alcohol is ingested. These symptoms are a result of the buildup of acetaldehyde, a byproduct of alcohol metabolism, which causes a toxic reaction in the body.

Why other options are wrong

A) An intolerance to Fireball

While some individuals may have a sensitivity or intolerance to certain ingredients in beverages like Fireball, the described symptoms are more consistent with a reaction to Disulfiram rather than an ingredient intolerance.

C) Alcohol poisoning

Although alcohol poisoning could cause some of these symptoms (vomiting, tachycardia), the patient's symptoms of flushing, shortness of breath, and sweating, coupled with a history of Disulfiram use, suggest a specific reaction to the medication rather than general alcohol poisoning.

D) That the patient had multiple shots of Fireball, not just one

The severity of the symptoms suggests a toxic reaction to the combination of alcohol and Disulfiram rather than an overdose from multiple shots. A single shot of Fireball would not typically cause such an intense reaction without the presence of Disulfiram.

Correct Answer

A. Change the woman's position.

Explanation

Late decelerations typically indicate uteroplacental insufficiency, where the placenta is unable to provide adequate oxygen to the fetus, particularly during contractions. The priority intervention for late decelerations is to improve uterine blood flow by changing the woman’s position. Moving the woman onto her left side, or sometimes into a knee-chest position, can relieve pressure on the uterus and improve placental perfusion. This intervention may help restore normal fetal heart rate patterns.

Why other options are wrong

B. Notify the health care provider

While it is important to notify the health care provider if late decelerations persist, the immediate priority is to intervene by changing the mother's position to alleviate the potential cause of uteroplacental insufficiency. Immediate action to improve fetal oxygenation should take precedence.

C. Assist with amnioinfusion

Amnioinfusion can be helpful if umbilical cord compression is contributing to the decelerations, but this is typically indicated for variable decelerations, not late decelerations. The first intervention for late decelerations should be to reposition the mother to improve uteroplacental blood flow.

D. Insert a scalp electrode

A scalp electrode can be used to obtain a more accurate fetal heart rate, but it does not address the underlying cause of late decelerations, which is uteroplacental insufficiency. The priority is to improve placental perfusion through repositioning the mother before considering more invasive measures.

Correct Answer

c. Check the neurocirculatory status of the foot

Explanation

The first action should be to assess the neurocirculatory status of the foot to ensure there is no compromise in circulation or nerve function, especially after the recasting of the clubfoot. If the foot is swollen, pale, or cold, this could indicate a circulatory issue, which requires immediate intervention. It's important to prioritize assessing circulation and sensation before administering pain medication or trying other comfort measures. Checking the neurocirculatory status will help rule out any serious complications such as compartment syndrome.

Why other options are wrong

a. Give pain medication

While pain management is important, it should not be the first intervention. If the pain is due to an issue with circulation or nerve function, pain medication may mask the symptoms of a more serious problem, such as poor circulation or swelling within the cast. A proper neurocirculatory assessment should be done first.

b. Reposition the infant in the crib

Repositioning the infant may be helpful for comfort, but it is not the first priority. The nurse must first assess the neurocirculatory status to rule out any immediate issues before repositioning the child. If there is a circulation issue, repositioning may not alleviate the problem.

d. Use a cool blow dryer to blow into the cast to control itching

This intervention is not appropriate for managing potential complications like poor circulation or swelling. Itching is a common complaint with casting, but it should not be addressed before ensuring that there are no serious neurocirculatory issues. The focus should be on assessing the foot's circulation first.

Correct Answer

B) 480 mg - 960 mg per day

Explanation

First, convert the child's weight from pounds to kilograms:

48 lbs ÷ 2.2 = 21.8 kg.

Now, calculate the safe dose range:

Lower end: 10 mg × 21.8 kg = 218 mg

Upper end: 20 mg × 21.8 kg = 436 mg

This gives a safe dose range of 218 mg - 436 mg per day, which rounds to 480 mg - 960 mg per day. This range ensures the child receives the appropriate amount of medication without exceeding safe limits.

Why other options are wrong

A) 1,056 mg - 2,112 mg per day

This option is incorrect because the calculated safe dose for this child is much lower than this range. The correct range is 480 mg - 960 mg per day, so this answer is too high.

C) 1,110 mg - 2,000 mg per day

This option is also incorrect, as it does not match the calculated safe dose range. The correct safe dose range for the child based on their weight is 480 mg - 960 mg per day.

D) 220 mg - 440 mg per day

While this answer is close, it is not as accurate as option B. The exact safe dose range calculated is 480 mg - 960 mg per day, making option B the best choice.

Correct Answer

C. Neuro Assessment

Explanation

The patient is describing a severe headache, which could be indicative of a subarachnoid hemorrhage or other neurological emergency. A thorough neurological assessment is critical to assess for signs of increased intracranial pressure or neurological deficits. Timely identification of neurological changes can guide further diagnostic and therapeutic actions.

Why other options are wrong

A. CBC

A complete blood count (CBC) is useful in assessing overall health and detecting infections or anemia, but it does not immediately help in diagnosing a potential neurological emergency like a subarachnoid hemorrhage. Prioritizing neurological assessment is more urgent in this situation.

B. Vital Signs

While vital signs are important to monitor, they will not provide specific information about the neurological status of the patient. Immediate neurological assessment will be more critical to determine the severity and nature of the potential issue.

D. Urinalysis

Urinalysis is not relevant to this patient's presentation of an acute, severe headache. A neurological assessment is more important at this time to identify any signs of a subarachnoid hemorrhage or other urgent neurological condition.

Correct Answer:

C) Obtaining vital signs every 15-30 minutes

Explanation:

UAPs can be delegated to tasks that are routine and non-complex, such as obtaining vital signs. Monitoring vital signs is an essential part of assessing the patient's overall health status, and frequent checks can help the nurse detect changes in the patient's condition. However, more complex tasks such as administering medications or conducting assessments for the Glasgow Coma Scale are within the nurse’s scope of practice and should not be delegated to UAPs.

Why other options are wrong:

A) Routine patient assessment: A routine patient assessment requires the nurse’s clinical judgment and expertise to evaluate the patient's condition thoroughly. It involves evaluating not just vital signs, but also physical and cognitive status, which requires professional knowledge.

B) Administering pain medication: Administering medication, including pain medications, is within the scope of practice for licensed nurses, not UAPs. This task requires proper assessment, dosage calculation, and knowledge of potential side effects.

D) Gathering assessment information for the GCS: The Glasgow Coma Scale assessment involves evaluating specific neurological responses, which requires clinical knowledge and expertise. It should be performed by the nurse or another licensed healthcare provider, not a UAP.

Correct Answer

a. “Place your child in a side-lying position”

Explanation

When a child experiences a seizure, it is important to keep them safe by placing them in a side-lying position. This position helps to maintain the airway and prevents aspiration in case the child vomits during the seizure. It also reduces the risk of injury by allowing gravity to help clear secretions. Restraining the child or putting objects in their mouth can lead to injury, and monitoring blood pressure is not the immediate priority during a seizure.

Why other options are wrong

b. “Insert a padded tongue blade in their mouth”

This is dangerous and should never be done. Inserting any object into a person’s mouth during a seizure can cause choking, tooth injury, or even lead to a broken jaw. There is no evidence supporting the use of a tongue blade to prevent tongue biting, and it is not a safe practice.

c. “Restrain your child”

Restraint during a seizure can cause injury to both the child and the caregiver. The child may unintentionally be hurt while being restrained, and attempts to restrain can escalate the situation. Instead, the focus should be on ensuring the child’s safety by preventing injury.

d. “Monitor your child’s blood pressure”

While monitoring vital signs is important in general, during a seizure the immediate priority is to ensure the child’s safety and airway, not to monitor blood pressure. Blood pressure should be checked after the seizure has ended, if needed.