ANSWER KEY FOR CASE STUDIES CHAPTER 7-56
ANSWER KEY Cooper: Foundations and Adult Health Nursing, 9th Edition CHAPTER 07 Nursing Care Plan 7-1: The Patient with an Infection 1. Mr. R. has a peripheral IV infusing and reports discomfort at the site of insertion. What
should the nurse do? The nurse should immediately assess the IV site for obvious dislodgment of the IV catheter, edema, erythema, or increased warmth or coolness. Coolness may indicate IV infiltration; the other signs may indicate irritation (possibly from a previously administered medication or as an adverse effect of it) or infection. In general, if an IV site is obviously infiltrated, nursing judgment is sufficient to determine whether to stop the IV infusion and/or remove the infiltrated IV catheter. Warm compresses may generally be applied per nursing judgment as well. (Facility policies must be verified.) The health care provider must be notified so that the determination can be made regarding the necessity to restart a new intravenous access site. 2. Mr. R. has a urinary catheter connected to continuous drainage. He reports burning at
the site of insertion and the nurse notes dark, concentrated urine in the tubing. What should the nurse do next? The nurse should assess the site of the catheter insertion for any signs of edema, erythema, or exudate. The nurse should then take the patient’s vital signs, noting any changes in temperature and pulse. Compare the data obtained with patient’s previous vital signs. Following these nursing actions, the nurse should obtain urine samples for urinalysis and culture and sensitivity (using aseptic technique), in anticipation of the health care provider’s orders to come. All of the above should then be reported to the patient’s health care provider as promptly as possible. The nurse should also encourage the patient to increase his fluid intake. Make additional fluids available to him, if not contraindicated. 3. The nurse notes on the sheet of laboratory results for the patient that his WBC count is 2800/mm3. Why is this a concern, and what is recommended as a precautionary TEACH Answer Key Cooper: Foundations and Adult Health Nursing, 9th Edition Copyright © 2023 by Elsevier Inc. All rights reserved.
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measure? This indicates a severely compromised immune system, placing the patient at very high
risk for infection. The patient is especially susceptible to microorganisms that normally do not pose a significant threat to a healthy immune system. A healthy immune system will destroy or deactivate most pathogens before they can multiply into greater numbers. If a patient is immunocompromised, even weaker or opportunistic pathogens (herpes varicella virus or CMV) can become established and cause infection or disease. Often this is in a more severe form because the patient also cannot initiate an effective immune response to combat it. Mr. R. should be placed on neutropenic precautions (formerly known as reverse isolation or Protective Isolation). The intent of neutropenic precautions is to minimize threats to the patient’s compromised immune status; for instance, protecting the patient from his or her environment. Most facilities have specific protocols for implementing neutropenic precautions. These generally involve a private room with the door to remain closed; limiting visitors; no obviously infected visitors; no fresh fruit, flowers, or raw vegetables; and no open containers (juices, water, etc.) which can serve as reservoirs for environmental pathogens.
ANSWER KEY Cooper: Foundations and Adult Health Nursing, 9th Edition CHAPTER 08 Nursing Care Plan 8-1: Patient With Activity Intolerance 4. The nurse is in the process of transferring Mr. D. from his bed to a chair using a
mechanical lift. The nurse has prepared the chair and placed it near the bed. The nurse turns Mr. D. to his side, places the sling under Mr. D. to ensure adequate support of his head, returns Mr. D. to his back, and slowly begins to lift Mr. D. from his bed. What has the nurse forgotten to do, and why is it important? The nurse has forgotten to fold Mr. D.’s arms across his chest to prevent them from becoming injured during the lift. 5. The patient has a trapeze bar across the bed, trochanter rolls, and a footboard. Explain
the rationale for each of these devices in maintaining proper body alignment. A trapeze bar allows the patient to use his upper body to move around in bed. Trochanter rolls stabilize the hip joint when placed firmly beside it, and prevent the hip from rolling outward. A footboard prevents permanent, abnormal plantar flexion (footdrop) resulting from injury to the flexor muscles.
ANSWER KEY TEACH Answer Key Cooper: Foundations and Adult Health Nursing, 9th Edition Copyright © 2023 by Elsevier Inc. All rights reserved.
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Cooper: Foundations and Adult Health Nursing, 9th Edition CHAPTER 09 Nursing Care Plan 9-1: Skin Care 6. Mr. P. has a poor appetite, and his chemistry profile reveals low protein, low albumin,
and low anion gap (A/G) ratio. Explain why poor nutrition predisposes to impairment of skin integrity and poor tissue healing. Proteins, which are synthesized by the liver, are required for tissue repair and proper immune system function. The only source of proteins is through dietary intake. If a patient is undernourished, he will be unable to produce adequate protein for metabolic processes, such as tissue repair and healing, and fighting infection. 7. With Mr. P.’s history of diarrhea, explain the possible complication that could evolve if
the dry intact skin develops an open lesion. It is possible that an open lesion in this anatomic region may become contaminated and infected with bacteria normally found in the intestines, notably Escherichia coli. This type of situation is often difficult to treat with antibiotics. As a further consequence of Mr. P.’s poor nutritional status, his immune system will be weakened and may not be able to effectively combat pathogens, making the infection even more difficult to manage.
ANSWER KEY Cooper: Foundations and Adult Health Nursing, 9th Edition CHAPTER 10 Nursing Care Plan 10-1: Patient Safety 8. The nurse walking down the hall hears a patient calling out for help. The nurse assesses
the situation and realizes that the patient does not remember how to use the call light. What factors possibly contribute to the patient’s inability to remember, and how should the nurse teach the patient to use the call light? A patient’s memory and cognitive function can be affected by a variety of factors, such as medications, anxiety, pain, disorientation, and dementia. Sensory perceptions should be assessed by the nurse as thoroughly as possible, with information and education being provided to patients and family/visitors appropriate to level of comprehension. Reinforcement of information should be provided as necessary. Demonstrations of the use of equipment (in this case, the call light) by the nurse and return demonstrations by the patient may be appropriate in some situations, particularly if the patient is in new or unfamiliar surroundings. It is also often helpful in this type of TEACH Answer Key Cooper: Foundations and Adult Health Nursing, 9th Edition Copyright © 2023 by Elsevier Inc. All rights reserved.
Cooper 9e Answer Key 4
situation if the nurse checks the patient frequently, both to assess the patient’s status and to reassure patients that they have not been left alone. Patients may need to be reoriented to surroundings frequently, especially if mental status changes are a concern. It is often helpful for a patient with sensory or cognitive impairment to be in a room close to the nurses’ station. 9. The nurse enters the patient’s room to answer the call bell and sees the patient frantically pointing to the trash can next to the bed. The nurse smells smoke and sees small flames. What should be done to help prevent fires, and what should the nurse do in this situation? The priority in this situation is to ensure patient safety. The nurse should call for assistance and implement the facility’s RACE protocol: Rescue/Remove the patient from the area; initiate the Alarm process; Contain the fire (close fire doors, patient room doors, etc.); Extinguish the fire, if realistic; and Evacuate the other patients, if necessary. Patients and visitors should be educated about facility safety policies: reinforce the no smoking policy; and the use of equipment and personal items (hair dryers, electric shavers, lamps, etc.) only if they meet appropriate facility codes. Safety reviews are generally conducted with facility personnel to ensure awareness of potential risks and proper safety procedures.
ANSWER KEY Cooper: Foundations and Adult Health Nursing, 9th Edition CHAPTER 16 Nursing Care Plan 16-1: The Patient With a Laceration 10. Ms. T.’s wound was superficial. In contrast, what would be the nurse’s actions if the
wound appeared to be deep or was spurting blood? Firm, direct pressure must be applied to the area (the nurse should be wearing gloves) and the patient must be observed for signs and symptoms of shock. The health care provider should be notified immediately by another nurse. 11. What safety measures are indicated to ensure Ms. T. is not injured again? Ms. T. may require more assistance or supervision during mealtimes than she did previously. For example, she may need her food cut up, perhaps before the meal is served to her (to prevent embarrassment).
ANSWER KEY Cooper: Foundations and Adult Health Nursing, 9th Edition TEACH Answer Key Cooper: Foundations and Adult Health Nursing, 9th Edition Copyright © 2023 by Elsevier Inc. All rights reserved.
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CHAPTER 20 Nursing Care Plan 20-1: Using Complementary and Alternative Therapies in Treatment 12. Ms. L. complains of feeling fatigued and tense. List some nonpharmacologic methods of
bringing about a state of physical and mental tranquility that may be helpful. Why may each of these methods be helpful for Ms. L.? Have Ms. L. try drinking some nonstimulating herbal tea, accepting a therapeutic massage, or positioning for comfort and relaxation. Decrease the stimulation of the environment by lowering the intensity of the lighting and listening to soothing music or nature sounds (especially rhythmic ones, such as waves or gentle rain). 13. Ms. L. turns on her light and she is crying. She complains of feeling helpless and
inadequate to assume responsibility for her children and husband when she is discharged. What are some therapeutic interventions that will promote her feelings of stability and validation of her anxiety? Allow and encourage Ms. L. to express her concerns and feelings. This may result in Ms. L. verbalizing more specific concerns regarding her perceived inability to assume her role in the family. Answering any questions she may have and offering information regarding the usual healing process may help to alleviate some of her anxiety.
ANSWER KEY Cooper: Foundations and Adult Health Nursing, 9th Edition CHAPTER 21 Nursing Care Plan 21-1: The Patient with Chronic Pain 14. During the morning ADLs, Mr. J. states, “I feel so useless. I can’t even place the urinal
for myself.” What would be the nurse’s most therapeutic response? Mr. J. should be encouraged to verbalize his concerns and frustrations. ―It sounds like this is very difficult for you,‖ ―You sound frustrated. Is that how you are feeling?‖ or ―Why don’t you tell me more about how you’re feeling?‖ may help him to feel he can safely express himself. As part of his ongoing care, Mr. J. should also be allowed as much choice and control over his nursing care and treatment regimen as possible, and should be given adequate time to perform those ADLs and self-care measures he can manage.
TEACH Answer Key Cooper: Foundations and Adult Health Nursing, 9th Edition Copyright © 2023 by Elsevier Inc. All rights reserved.