Difficulty: Medium
Average Score: 82%
Simulated
Passage / Scenario
History and PhysicalA 75-year-old male presents to the emergency department (ED) with poorly controlled diabetes. He had been experiencing polyuria, nausea and vomiting, confusion, and unstable blood sugars. The client was stabilized in the ED and transferred to the medical unit for continued stabilization and management. The client has a history of smoking and has smoked one pack per day for the past 40 years. There is a history of moderate obesity, insulin-dependent diabetes, and mobility issues. He requires the use of a walker for mobility..
NurseÔÇÖs Notes
17:35
The client is moved from the gurney to the medical bed and requires two people to assist. The nurse performs a functional assessment. The client reports neuropathy in bilateral hands and lower legs. His skin is moist. He reports the need to wear an incontinence brief due to occasional accidents of both urine and stool. He explains that it is difficult for him to move quickly enough when he feels the urge to use the bathroom. At home, where he lives alone, he reports spending most of his time in his recliner, though he can ambulate within the home and does so if needed. He feels like he slides in bed to move because repositioning is difficult. He is currently using a front-wheeled walker. He reports difficulty eating a full meal and has less than optimal PO intake. Contracting sounds are noted.
17:35
The perineal area is noted to have redness with no open sores. The client has blanchable redness noted on both heels bilaterally and on the coccyx
Lab Results
Laboratory Test
Result
Reference Range
Glucose 180 mg/dl (10 mmol/L) 74 to 106 mg/dl (4.1 to 5.9 mmol/L)
Flow Sheet
17:15
Vital Signs and Assessments:
ÔÇó Temperature: 98.7┬░F (37┬░C)
ÔÇó Heart rate: 94 beats/minute
ÔÇó Respiratory rate: 18 breaths/minute
ÔÇó Blood pressure: 138/88 mmHg
ÔÇó Oxygen saturation: 95% on room air
ÔÇó Pain: 3 on a 0 to 10 pain scale, baseline numbness and tingling in bilateral upper and lower extremities
ÔÇó Braden score: 13
Orders
17:15
ÔÇó Capillary blood glucose before meals and bedtime
The nurse reviews the clientÔÇÖs data.Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the clientÔÇÖs progress.
Rationale
Choice A reason:
There is no mention of an open wound that requires cleansing and dressing, so this action is not applicable based on the provided patient data.
Choice B reason:
The patient has blanchable redness on both heels and the coccyx, which are signs of pressure injury risk. Ofloading these areas is essential to prevent the development of pressure ulcers.
Choice C reason:
There is no indication of elder abuse in the provided scenario, so contacting adult protective services would not be appropriate.
Choice D reason:
Given the patient's difficulty with mobility and the reported occasional accidents, a bowel training program could help manage his bowel incontinence and improve his quality of life.
Choice E reason:
An enema is not indicated as there is no evidence of constipation or bowel obstruction in the patient's history or nurse's notes.
Condition F reason:
The patient is most likely experiencing pressure injuries, as indicated by the redness on his heels and coccyx, which are common sites for pressure ulcers due to immobility.
Condition G reason:
There is no evidence of elder abuse in the patient's history or nurse's notes. Condition H reason:
Altered nutrition may be a concern due to the patient's reported difficulty eating full meals and less than optimal intake, but it is not the primary condition indicated by the nurse's assessment.
Condition I reason:
There is no evidence of bowel obstruction; the patient's main issue seems to be related to pressure injury and incontinence.
Parameter J reason:
Monitoring wound status is crucial for managing and tracking the healing process of any existing or potential pressure injuries.
Parameter K reason:
While documentation of skin prevention measures is important, it is not as immediate as monitoring wound status and incontinence episodes.
Parameter L reason:
Monitoring incontinence episodes will help evaluate the effectiveness of the bowel training program and any other interventions put in place to manage the patient's incontinence.
Parameter M reason:
Vital signs should always be monitored, but they are not specific to assessing the progress of pressure injury management or bowel training program effectiveness.
Parameter N reason:
Family dynamics are not relevant in this case as the patient lives alone and there is no indication of family involvement in his care.
There is no mention of an open wound that requires cleansing and dressing, so this action is not applicable based on the provided patient data.
Choice B reason:
The patient has blanchable redness on both heels and the coccyx, which are signs of pressure injury risk. Ofloading these areas is essential to prevent the development of pressure ulcers.
Choice C reason:
There is no indication of elder abuse in the provided scenario, so contacting adult protective services would not be appropriate.
Choice D reason:
Given the patient's difficulty with mobility and the reported occasional accidents, a bowel training program could help manage his bowel incontinence and improve his quality of life.
Choice E reason:
An enema is not indicated as there is no evidence of constipation or bowel obstruction in the patient's history or nurse's notes.
Condition F reason:
The patient is most likely experiencing pressure injuries, as indicated by the redness on his heels and coccyx, which are common sites for pressure ulcers due to immobility.
Condition G reason:
There is no evidence of elder abuse in the patient's history or nurse's notes. Condition H reason:
Altered nutrition may be a concern due to the patient's reported difficulty eating full meals and less than optimal intake, but it is not the primary condition indicated by the nurse's assessment.
Condition I reason:
There is no evidence of bowel obstruction; the patient's main issue seems to be related to pressure injury and incontinence.
Parameter J reason:
Monitoring wound status is crucial for managing and tracking the healing process of any existing or potential pressure injuries.
Parameter K reason:
While documentation of skin prevention measures is important, it is not as immediate as monitoring wound status and incontinence episodes.
Parameter L reason:
Monitoring incontinence episodes will help evaluate the effectiveness of the bowel training program and any other interventions put in place to manage the patient's incontinence.
Parameter M reason:
Vital signs should always be monitored, but they are not specific to assessing the progress of pressure injury management or bowel training program effectiveness.
Parameter N reason:
Family dynamics are not relevant in this case as the patient lives alone and there is no indication of family involvement in his care.