Question #1 by Ana Frota Penha

What specific HEENT findings should be monitored during the assessment of an oncology patient, particularly one undergoing radiation therapy to the head and neck region, to identify potential complications such as mucositis, xerostomia, and impact on swallowing and nutrition?

Model Answer:

During the HEENT assessment of an oncology patient receiving radiation therapy to the head and neck, it’s essential to monitor for the following specific findings:

• 1. Mucositis: Look for signs of inflammation and ulcerations in the oral cavity and oropharynx. Patients may report pain, difficulty swallowing (dysphagia), or a sore throat. Ulceration can significantly impact their ability to eat and maintain nutrition.

• 2. Xerostomia (Dry Mouth): Assess for dryness of the oral mucosa, which can lead to difficulties in swallowing, speaking, and tasting food. This condition can be assessed by asking the patient about their symptoms and examining for moistness in the oral cavity.

• 3. Swallowing Function: Evaluate the patient’s ability to swallow liquids and solids. Observe for any choking, coughing during meals, or changes in dietary preferences due to ease of swallowing.

• 4. Oropharyngeal Examination: Inspect the throat, including the tonsils and uvula, for any signs of inflammation, swelling, or lesions that could indicate secondary infections due to compromised immunity.

• 5. Ears: Monitor for any reported hearing changes, as radiation therapy can impact the ears or lead to complications such as ear infections.

• 6. Nasal Passages: Check for nasal dryness, bleeding, or obstruction. Patients may experience changes in the nasal mucosa due to treatment.

• 7. Oral Hygiene: Assess the patient's oral hygiene practices, as poor oral hygiene can exacerbate mucositis and lead to secondary infections.

Overall, these findings are vital for developing a comprehensive care plan aimed at minimizing complications and improving the patient's quality of life. Regular HEENT assessments allow for early intervention, ensuring that any issues with mucositis, xerostomia, or swallowing are managed effectively. This approach significantly impacts the patient’s nutritional status and emotional well-being during treatment.

The Intention of the Question: 

The intention of the question is to encourage a closer look at the HEENT (Head, Eyes, Ears, Nose, and Throat) assessment in oncology patients receiving radiation therapy to the head and neck. It focuses on raising awareness about potential complications like mucositis and xerostomia, which can greatly affect a patient's quality of life and ability to eat or speak. By emphasizing the need for thorough evaluations, the question highlights the importance of detecting issues early so that healthcare teams can provide timely support and interventions. Ultimately, it underscores the need for a collaborative approach among healthcare professionals to address the unique physical and emotional challenges faced by these patients, ensuring they receive compassionate and comprehensive care throughout their treatment journey.

References

Haber J, Hartnett E, Allen K, Hallas D, Dorsen C, Lange-Kessler J, Lloyd M, Thomas E, Wholihan D. Putting the mouth back in the head: HEENT to HEENOT. Am J Public Health. 2015 Mar;105(3):437-41. doi: 10.2105/AJPH.2014.302495. Epub 2015 Jan 20. PMID: 25602900; PMCID: PMC4330841.

Pisani C, Mastroleo F, Collo A, Ferrante D, Carabelli G, Franco P, Riso S, Dell'Era V, Garzaro M, Aluffi Valletti P, Krengli M. Variation in Body Mass and Skeletal Muscle Indices in Head and Neck Cancer Patients Undergoing (Chemo)Radiotherapy and Nutritional Intervention. Curr Oncol. 2022 Dec 24;30(1):250-260. doi: 10.3390/curroncol30010020. PMID: 36661669; PMCID: PMC9857332.

Model Answer:

The patient will undergo a multi-phased, staged facial reconstruction. The first procedure is a cranial vault expansion, performed in infancy, in which the prematurely fused cranial sutures are released to allow for cranial reshaping (CHILDRENS). The second procedure would likely be a LeFort III in which the midface bones are moved outward and fixed with hardware between ages 7-10 (Slota, 2006). Other surgical options are a monobloc facial reconstruction (advancing the forehead and midface together, between ages 7-10), a box osteotomy (adolescence) and/or orthognathic surgery to improve bite in the teen years

The Intention of the Question: 

Craniofacial abnormalities like those seen with Crouzon’s are common in pediatric care. The surgical reconstruction is done in stages over many years, so by the point that surgical repair is complete, the patients and families have endured many procedures and hospital stays.  

While cosmetic improvements are some of the justifications for the procedures, improving breathing, allowing for cranial valut expansion, creating a patent airway and other physiologic indicators are the key reasons for surgical intervention. 

Healthcare professionals caring for these children pre, intra and post operatively (as well in a general peds outpatient setting) should know about the many interventions necessary for these patients.

References

Nationwide Children's Hospital. (n.d.). Crouzon syndrome: Causes, symptoms, diagnosis and surgical treatment. Retrieved April 14, 2025, from https://www.nationwidechildrens.org/conditions/crouzon-syndrome 

Slota, M.C. (2006). Core curriculum for pediatric critical care nursing. Saunders. 

Model Answer:

• 1. To test peripheral fields, the nurse would perform the confrontation test (Ball et al., 2023). The patient would cover one eye, and the nurse would sit approximately 3 feet away covering the opposite eye. The nurse would then extend their arm between themselves and the patient, and wiggle their fingers as they slowly bring their hand closer to the center, asking the patient to report to the nurse when they can see the nurse’s fingers. This should be compared to when the nurse can first see their fingers. This is repeated with the nasal, temporal, superior and inferior fields. An abnormal test would be the patient reporting seeing the nurse’s fingers well after the nurse sees them in comparison.

• 2. The concern shown in the photo is papilledema.

• 3. Diagnostics: with the papilledema and the headaches, concern would be for intracranial hypertension (Chen et al., 2023). Follow up with MRI with or without contrast and lumbar puncture would be beneficial (Friedman et al., 1998). Treatment would include starting on medications to bring down the pressure in her head and also prevent it from creeping back up, this is often done with a course of oral steroids and a diuretic, acetazolamide. Continuous follow-up with neuro-ophthalmology and neurology is recommended. 

The Intention of the Question: 

The intention of this question is for the nurse to review what assessments skills are needed when assessing a patient’s peripheral visual field. Additionally, this question aims to have the nurse think critically about next steps when a patient presents abnormally with an eye exam, and how a patient that has papilledema should be further worked up and treated.

Referencee

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W., & Seidel, H. M. (2023). Seidel’s guide to physical examination (Tenth edition.). Elsevier.

Chen, B. S., & Britton, J. O. T. (2023). Expanding the clinical spectrum of idiopathic intracranial hypertension. Current Opinion in Neurology, 36(1), 43–50. https://doi.org/10.1097/WCO.0000000000001131 

Friedman, D., Forman, S., Levi, L., Lavin, P., & Donahue, S. (1998). Unusual ocular motility disturbances with increased intracranial pressure. Neurology, 50(6), 1893–1896. https://doi.org/10.1212/WNL.50.6.1893 

Question #4 by Emily Watson

Peter, a 58-year-old man, presents to urgent care with a sudden onset of visual disturbances in his right eye. He describes seeing flashes of light and an increase in floaters earlier in the day, followed by what he describes as a "curtain coming down" over part of his visual field. He denies pain, redness, or discharge. His past medical history includes high myopia and cataract surgery two years ago. Based on Peter's symptoms and physical assessment, what is the most likely diagnosis, what is the most appropriate treatment option for this condition, and what recovery instructions should the nurse be sure to explain?

Model Answer:

Peter’s presentation is classic for a rhegmatogenous retinal detachment—a medical emergency where a retinal tear allows vitreous fluid to enter and separate the retina from the retinal pigment epithelium. This can lead to permanent vision loss if not treated promptly. Key features include, flashes (photopsia) and floaters suggesting vitreoretinal traction; the “curtain” effect reflects progressive detachment. High myopia and previous cataract surgery increase his risk due to retinal thinning and vitreous changes.

Most Appropriate Treatment Option: Pars Plana Vitrectomy (likely choice in Peter’s case due to prior surgery and age). This procedure involves removing the vitreous gel that’s pulling on the retina. The space is replaced with a gas bubble or silicone oil, which presses the retina back into place. Often used in complex or posterior retinal detachments, especially in patients with prior cataract surgery or extensive detachment.

Recovery Instructions the Nurse Should Explain: Recovery instructions for Peter should include specific guidance to promote healing and prevent complications following retinal detachment surgery. He may be required to maintain a specific head position—such as face-down or side-lying—for several days, depending on the location of the gas bubble placed during surgery. This positioning is critical to keep the bubble in contact with the retinal break to support reattachment. Peter should avoid strenuous activities, bending over, or lifting heavy objects, and he must not travel by air until cleared by his ophthalmologist, as gas expansion at high altitudes can dangerously increase intraocular pressure. Eye care is essential; he should wear an eye shield, especially while sleeping, and avoid touching or rubbing the eye. He will be prescribed antibiotic and anti-inflammatory eye drops that must be used exactly as directed, and mild post-operative discomfort can be managed with oral pain relievers. Peter should be instructed to report any signs of complications immediately, including worsening or new vision loss, severe eye pain, increased redness or swelling, new floaters or flashes, or any eye discharge. Finally, he must attend all follow-up appointments to monitor healing, retinal position, and intraocular pressure, and he may require long-term follow-up to evaluate for recurrent detachment or the development of a cataract if one is not already present.

The Intention of the Question: 

The quiz question intends to evaluate the learner’s ability to recognize rhegmatogenous retinal detachment based on classic symptoms such as sudden onset of flashes of light, increased floaters, and the sensation of a curtain descending over the visual field. It tests the student’s ability to connect these symptoms with known risk factors like high myopia and a history of cataract surgery, which predispose the patient to retinal tears. The question also assesses knowledge of the most appropriate treatment, such as pars plana vitrectomy, and requires the learner to understand the nurse’s role in post-operative care, including instructing the patient on head positioning (to keep a gas bubble in place), avoiding air travel, and monitoring for signs of complications like worsening vision or pain. This encourages the application of pathophysiology, clinical judgment, and patient education in a realistic clinical scenario.

References

DynaMedex. Retinal Detachment. EBSCO Information Services. Accessed April 14, 2025. https://www-dynamedex-com.offcampus.lib.washington.edu/condition/retinal-detachment#GUID-8D62CB92-DD9D-482D-9CCA-762311C049F8 

Steel D. (2014). Retinal detachment. BMJ clinical evidence, 2014, 0710. https://pmc-ncbi-nlm-nih-gov.offcampus.lib.washington.edu/articles/PMC3940167/ 

Model Answer:

Acute otitis media (AOM) is the most common infectious disease encountered by children under the age of two years and the most common cause of antibiotic use in children in the United States. AOM causes irritability, sleeplessness, decreased appetite, imbalance, and dizziness in patients, especially young children. Various etiologies have been associated with AOM, such as the biology of the middle ear cleft, differences in anatomical structures between individuals, nasopharynx cell biology, and variations in the immune response to microbial invasions. Viral pathogens, bacterial pathogens, and genetics have all been associated with AOM; however, bacterial pathogens are believed to be the main causative agents of AOM. The pathophysiology of AOM is simply due to inflammation in the eustachian tube (ET), which prevents fluid drainage from the middle ear cavity, and this fluid retention eventually turns into purulent effusion, which is characteristic of AOM. The middle ear cavity is normally a sterile site. The presence of viral or bacterial pathogens, and that, alongside allergic reactions, is usually the initiation factor for ET inflammation that will eventually develop into a sequela of AOM. Treatment of recurrent AOM is divided into two categories: medical and surgical. Medical therapy is mainly attributed to the use of topical antiseptics and topical and oral antibiotics, and surgical treatment is mainly performed by inserting a tympanostomy tube into the middle ear cavity (Pirozzo & Del Mar, 2001)

The Intention of the Question: 

I was once a public health pediatric RN and we received many cases of acute otitis media (AOM) post-emergency department visits for children six months to two years old in our clinic. Since AOM is common amongst children, it is a must that we are able to recognize its etiology, clinical presentations, diagnosis and treatment. This scenario-based question aims to facilitate the critical thinking and active learning of students as they reflect on the child’s clinical presentations and utilize parent’s narratives of history and present illness. This is also a situation where it warrants for the RN to speak up, and question a physician decision regarding discharge planning and diagnosis. This helps us become more effective advocate for patient’s safety. In doing so, professionalism, clinical knowledge and practice is employed. 

References

Jamal, A., Alsabea, A., Tarakmeh, M., & Safar, A. (2022). Etiology, Diagnosis, Complications, and Management of Acute Otitis Media in Children. Cureus, 14(8), e28019. https://doi.org/10.7759/cureus.28019 

Pirozzo, S., & Del Mar, C. (2001). Acute otitis media. The Western journal of medicine, 175(6), 402–407. https://doi.org/10.1136/ewjm.175.6.402 

Model Answer:

Assessment would include: 

• 1. Temperature check- anything over 100.4 is considered a fever and will warrant a pickup. 

• 2. Health history, call parents/guardians. Confirm reason for staying home. Cold? Past ear infections? Hearing concerns. 

• 3. Outer ear assessment- look for anything that could be causing discomfort 

• 4. Inner ear otoscope assessment: you find they have bilateral membrane bulging, fluid buildup and discoloration of the membrane. Also look for any foreign objects, cuts and wax built up. Use the down and back technique for young children

• 5. Pain. Ask about pain, is it something that would warrant going home or parents to give pain meds. 

• 6. Behavior- younger kids at time are not able to report feelings such as pain. Look for other non-verbal queues like inattention, fussiness, or balance issues.

• 7. Hearing assessment-using the weber and rinne test. Schools have assess to an audiometer and I would use that to see id they pass at the 1000. 2000, 4000 hz at 20db

The nurse suspects Otitis Media with Effusion. Staying at school is allowed and letting teacher know that the student will need some accommodations due to the temporary hearing loss, such as sitting closer to teacher, talking directly to the student, repeating instructions. 

The Intention of the Question: 

This question is to elicit critical thinking in a non-medical setting. In the school setting not all medical conditions require that students be sent home. In this case the student is managing the symptoms well, not in pain, and no fever. The nurse would call home and report findings, let family know that the student is ok to be at school but should follow up with a provider to confirm nursing assessment. This question will also elicit a reminder that there are many ear related conditions with similar symptoms including some that are due to self-injury.  

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W., & Seidel, H. M. (2023). Seidel’s guide to physical examination (Tenth edition.). Elsevier.

Ball, J. W., & Bindler, R. C. (2016). Principles of pediatric nursing (7th ed.). Pearson.

BMJ Best Practice. (2023, May 23). Otitis media with effusion. BMJ. https://bestpractice.bmj.com/topics/en-us/3000306 

Model Answer:

The provider is likely to recommend the first line treatment for snoring with apnea from adenotonsillar hypertrophy, an adenotonsillectomy (Marcus et al., 2012). For the otitis media with effusion, I would expect a tympanostomy tube to be placed during the surgery (Chi & Tobey, 2023). The parents are understandably nervous. I would reassure them that this is a common, safe procedure and is the first line treatment with positive long-term outcomes, in which the benefits of this surgery outweigh risks (Marcus et al., 2012). Pre/post op teaching would include monitoring the child’s airway for swelling, monitoring for bleeding, and would include return precautions such as vomiting blood (Marcus et al., 2012). Pain control is pivotal to ensure comfort for rest and to be able toswallow secretions and fluid for hydration. Around the clock Tylenol and ibuprofen is recommended, and favorite popsicles and drinks should be on hand.  

The Intention of the Question: 

This question is intended to have students apply findings in a HEENT exam to likely intervention, and apply nursing skills and knowledge to educate the family on surgical post-op care. My daughter is scheduled for this surgery and I am very nervous so I was hoping for some discharge teaching and reassurance from my classmates! 

References

Chi, D.A., & Tobey, A. (2023). Otolaryngology. In B.J. Zitelli, S.C. McIntire, A.J. Nowalk, & J. Garrison (Eds.), Zitelli and Davis’ atlas of pediatric physical diagnosis (pp. 873-922). Elsevier, Inc

Marcus, C. L., Brooks, L. J., Draper, K. A., Gozal, D., Halbower, A. C., Jones, J., Schechter, M. S., Sheldon, S. H., Spruyt, K., Ward, S. D., Lehmann, C., & Shiffman, R. N. (2012). Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. Pediatrics, 130(3), 576–584. https://doi.org/10.1542/peds.2012-1671 

Model Answer:

B. Cerumen impaction – inspect ear canal with an otoscope and perform irrigation 

Rationale:

Lisa’s history is quite complex, and any of these answers are appropriate differential diagnoses. However, this is an acute event, and she describes no recent changes in her health. This has never happened before, and continuing dizziness and tinnitus in conjunction with high blood pressure would rule out orthostatic hypotension (Palma & Kaufmann, 2024). If her levothyroxine dose is too low, she could be experiencing exacerbated symptoms of hypothyroidism. Tinnitus, hearing loss, and syncope are all symptoms of hypothyroidism (Brashers et al., 2019), but she does not describe other common symptoms such as fatigue, cold intolerance, and integument changes ruling out levothyroxine dosing as the cause. Lisa takes several medications that can cause dizziness including losartan (Zambroski, 2023) and exemestane (UpToDate, 2025), but those are relatively rare side effects and an unlikely cause as these medications are not new. 

Cerumen impaction can cause dizziness due to disruption of the normal pathway of hearing. The tympanic membrane transmits vibrations to the malleus, incus, and stapes which travel to the inner ear. The inner ear is composed of the cochlea, vestibule, and semicircular canals. Within this structure equilibrium receptors are influenced by small otoliths, sometimes referred to as crystals, that are essential to balance (Huether & Rodway, 2019). By blocking the pathway to the inner ear equilibrium can be affected in some cases of cerumen impaction (Dinces, 2025). Lisa’s tinnitus, difficulty hearing, and recent air travel should trigger the learner to consider assessment of her ears and decide to irrigate based on the severity of her symptoms.

The Intention of the Question: 

This is a true story based on my mom! She has a very complex medical history but is relatively healthy considering her problem list and medications. When I took her to urgent care for this visit, I was concerned about something more serious due to her co-morbidities. But this experience taught me that sometimes a simple problem can cause serious symptoms. My goal is for the learner to look past the complex medical history and consider the acute information before them to come to a diagnosis. By carefully listening to Lisa’s subjective data (signs of vertigo, tinnitus, acute onset) and objective observation (hard of hearing), the answer should be clear.

References

Brashers, V. L., Jones, R. E., & Huether, S. E. (2019). Alterations of hormonal regulation. In K. L. McCance & S. E. Huether (8th Ed.), Pathophysiology: The biological basis for disease in adults and children (pp. 669-712). El Sevier. 

Dinces, E. A. (2025, March 5). Cerumen. UpToDate. Retrieved April 13, 2025 from https://www.uptodate.com/contents/cerumen?search=cerumen%20impaction&source=search_result&selectedTitle=1%7E22&usage_type=default&display_rank=1  

Huether, S. E., & Rodway, G. W. (2019). Pain, temperature regulation, sleep, and sensory function. In K. L. McCance & S. E. Huether (8th Ed.), Pathophysiology: The biological basis for disease in adults and children (pp. 468-503). El Sevier. 

Palma J., & Kaufmann, H. (2024, August 16). Mechanisms, causes, and evaluation of orthostatic hypotension. UpToDate. Retrieved April 13, 2025, from https://www.uptodate.com/contents/mechanisms-causes-and-evaluation-of-orthostatic-hypotension?search=postural%20hypotension&source=search_result&selectedTitle=2%7E150&usage_type=default&display_rank=2 

UpToDate Lexidrug. (2025). Exemestane: Drug information. Retrieved April 13, 2025 from https://www.uptodate.com/contents/exemestane-drug-information?source=auto_suggest&selectedTitle=1~2---1~2---exem&search=exemestane 

Zambroski, C. H. (2023). Antihyperlipidemic medications. In C. G. Visovsky, C. H. Zambroski, & R. M. Lutz (5th Ed.), Edmunds’ pharmacology for the primary care provider (pp. 142-156). El Sevier. 

Model Answer:

• 1. The mole-like spot is asymmetric, has irregular borders, with color varying from black to dark brown, and is 9mm in diameter. The patient said this is it has grown larger from when they first noticed it.

• 2. I suspect the patient may have superficial spreading melanoma because he is aged 55 years old and has a history of HIV. Melanoma commonly presents in adults 35-65 years old and those with immunosuppression have higher risk. The mole itself meets the ABCDE criteria, especially since this mole is new and he has no other moles on his body. Superficial spreading melanoma is typically asymmetric, with varying colors, and border irregularities.

• 3. Some additional questions I would ask the patient is:

  • a. Do you have a personal or family history of melanoma or other skin cancers?

  • b. Do you spend a lot of time in the sun (excessive sun exposure) or use tanning beds frequently?

  • c. Did you ever suffer from severe sunburns? If so, have you ever had blisters from it?

  • d. Does the mole area ever get itchy or bleed?

  • e. When did they first notice the mole?

  • f. Has the mole changed is appearance besides the size?

The Intention of the Question: 

This question is based off an experience from my colleague. She told me that patient ended up seeing an outpatient dermatologist who diagnosed the mole with melanoma. They were fortunate to caught it early. The patient was grateful because they lived alone and didn’t think much of it at first.

References

DynaMedex. Melanoma. EBSCO Information Services. Accessed April 14, 2025. https://www.dynamedex.com/condition/melanoma 

Swetter, S., & Geller, A. (2023, October 4). Melanoma: Clinical features and diagnosis. UpToDate. https://www-uptodate-com.offcampus.lib.washington.edu/contents/melanoma-clinical-features-and-diagnosis?search=melanoma&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#H81531020 

Question #10 by Lindsey Bui

John, a 45-year-old man, came into the clinic because his wife noticed an irregularly shaped mole (nevus) on his back. He generally has a large number of moles on his body and didn’t think anything of it, but his wife was concerned because the one on his back does not look like the others. John’s mother has a history of melanoma, and he works outside daily in construction. 

As his nurse, what features of the nevus would you assess? How would you know if this was a normal nevus, atypical/dysplastic mole, or melanoma? 

Model Answer:

As John’s nurse, I would assess the moles for color, shape, surface, size, number, and location to determine whether his nevus presents with typical or atypical features (Ball et al., 2023). For color, normal nevi are uniformly tan or brown, and they all look alike on the body compared to atypical nevi that have a mixture of colors (tan, brown, black, red/pink) and do not look alike (Ball et al., 2023). Normal nevi are round or oval with defined borders compared to atypical nevi with irregular borders that may fade into the surrounding skin or include flat portions level with the skin (Ball et al., 2023). The surface of normal nevi begins flat/smooth on the skin and can become raised to form smooth bumps compared to atypical nevi, which could be smooth, scaly, or have a rough/irregular appearance (Ball et al., 2023). Normal nevi are usually less than 6mm compared to atypical nevi larger than 6mm (Ball et al., 2023). Adults tend to have 10-40 nevi scattered on their bodies, whereas people with atypical nevi could have more than 100 nevi (Ball et al., 2023). Finally, normal nevi are generally located above the waist on areas with increased sun exposure compared to atypical nevi that can occur anywhere on the body, with most being on the back, below the waist, scalp, breast, and buttock (Ball et al., 2023). 

To distinguish between dysplastic/atypical moles and melanoma, the nurse would see that in melanoma, the borders are more irregular, greater than 6mm in size, with color variations within the mole ranging from tan, brown, black, pink, grey, red, blue, or white (Ball et al., 2023). Dysplastic moles are generally located on the trunk, have poorly defined borders, are larger than 5mm in size with a flat component, and are round, oval, or irregular in shape, with color consisting of mainly brown but can have spots of dark brown, pink, and tan (Ball et al., 2023). Some people can have multiple dysplastic moles that do not turn into melanoma, but they are at high risk for melanoma (Ball et al., 2023). 

To further assess the mole, the nurse could use the ABCDE route, looking for asymmetry, border, color, diameter, and evolving to see if the mole is changing in size, shape, or color over time (Tsao et al., 2015). Melanoma moles/lesions can increase in size, change color, and shape, so a biopsy is needed to examine and diagnose them (Banasik & Copstead, 2018).

The Intention of the Question: 

I have taken care of patients with metastatic melanoma in the past and was inspired to write this question based on that experience. This question touches not only on assessment skills but also the knowledge application needed to distinguish between regular nevi, atypical nevi, and melanoma. Since it is now spring and summer is approaching, it never hurts to be reminded about the importance of skin protection as well!

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart. R. W. (2023). Seidel’s guide to physical examination. Elsevier Inc. https://www-clinicalkey-com.offcampus.lib.washington.edu/#!/content/book/3-s2.0-B9780323761833000231?scrollTo=%23top 

Banasik, J. L., & Copstead, L. E. (2018). Pathophysiology. Elsevier Inc. https://ebookcentral.proquest.com/lib/washington/detail.action?docID=5434807 

Tsao, H., Olazagasti, J. M., Cordoro, K. M., Brewer, J. D., Taylor, S. C., Bordeaux, J. S., Chren, M., Sober, A. J., Tegeler, C., Bhushan, R., & Smith Begolka, W. (2015). Early detection of melanoma: Reviewing the ABCDEs. Journal of American Academy of Dermatology, 72(4), 717-723. https://doi.org/10.1016/j.jaad.2015.01.025 

Model Answer:

Based on the image provided, John has an unstageable pressure injury. The pressure injury is unstageable due to slough preventing the nurse from being able to visualize the wound bed to appropriately stage the wound. Some potential interventions that could be utilized to help treat John’s pressure injury are keeping the wound dry and covered to help limit risk of infection, pressure redistribution through utilization of items such as low air loss mattresses and turning/positioning devices, promoting adequate calorie and protein intake so that the body is best able to heal, and ensuring proper glycemic control to limit the risk of high blood glucose levels impairing wound healing.

The Intention of the Question: 

The patient in this scenario is based on my father. He was paralyzed in a car accident over 10 years ago and developed a pressure ulcer while in the ICU due to being too medically unstable to tolerate turning. While it didn’t initially look nearly as bad as the one in the photo, the pressure injury ended up involving much more tissue than the healthcare workers could see, and he ended up needing a flap surgery where they took about a brick sized amount of necrotic tissue. While we need to prioritize the patient’s immediate health, it really is important to do everything in our power to at least try to assess all bony prominences on patients that are confined to bed, especially those that are paralyzed.

References

Berlowitz, D. (2023, August 16). Clinical staging and general management of pressure-induced skin and soft tissue injury. UpToDate. https://www-uptodate-com.offcampus.lib.washington.edu/contents/clinical-staging-and-general-management-of-pressure-induced-skin-and-soft-tissue-injury?search=pressure%20ulcer&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#H1 

Naqvi, S. H., Osundolire, S., Goldberg, R. A., Lapane, K., & Nunes, A. P. (2023). Unhealed pressure ulcers among nursing home residents with diabetes. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.4325852

Thomas, S. (2014, February 6). Sloughy sacral pressure ulcer, sore. Medetec.co.uk. https://www.medetec.co.uk/slide%20scans/pressure-ulcer-images-a/target79.html 

Question #12 by Patrick Shinsky

A 26-year-old woman presents to her primary care provider (PCP) with months of fatigue, anxiety, depression, forgetfulness, weight loss, sleep disturbance, dry eyes, muscle weakness, joint pain, and swelling in the ankles following an extended period of standing. Although not active now, she also reports a diffuse mild rash that occurs randomly and discoloration that becomes prominent when sitting in the sun for too long (reference images). The provider referred her to a rheumatologist and ordered some diagnostic lab work.

What is the likely diagnosis based on these symptoms? Name at least three labs (there are quite a few) you would expect to be ordered to confirm the diagnosis.

Model Answer:

The diagnosis is systemic lupus erythematosus. There are no definitive tests that would result in a positive diagnosis but rather a combination of lab results and symptoms (Ball et al., 2023).

Labs may include (Ball et al., 2023; Campbell & Patel, 2025): 

• Antinuclear antibodies: if positive in combination with anti-dsDNA antibodies, low complement levels, or anti-Sm antibodies it is highly suggestive of systemic lupus erythematosus 

• Complement levels (C3, C4, CH50)

• Antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, anti–β₂-glycoprotein)

• Direct Coombs test

• Erythrocyte sedimentation rate or C-reactive protein level

• CMP

• CBC

• Urinalysis

• Thyroid-stimulating hormone

• Rheumatoid factor (RF)

• Anti-cyclic citrullinated peptide (anti-CCP) antibody

The Intention of the Question: 

This question is based on a family member experiencing these symptoms for months. She had gone to her PCP multiple times and ended up switching PCPs to be taken seriously about her symptoms. She finally had her new PCP order a series of lab work and referred her to a rheumatologist. Ultimately, she was diagnosed with SLE and is now feeling much better as her flares are under better control, and she made the appropriate lifestyle changes. 

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W., & Seidel, H. M. (2023). Seidel’s guide to physical examination (Tenth edition.). Elsevier.

Campbell, S. L., & Patel, N. K. (2025). Proactive identification of systemic lupus erythematosus: Detailed examination of early signs and symptoms for timely diagnosis. Nurse Practitioner, 50(2), 12–16. https://doi-org. offcampus.lib.washington.edu/10.1097/01.NPR.0000000000000276 

Question #13 by Suman Roy

A 30-year-old male came to the ER with complaints of painful abscesses on his right arm and left thigh, which he believes are the results of recent unsafe injection of a drug.  His last infection was 24 hours ago, and he mentions using a dirty needle he found at a friend's house. He reports fever, chills and increased pain in the abscessed areas. the abscesses are red, swollen and tender to touch, and he describes the drainage as pus-like. patient has hx of several infections related to the abscesses from the injections, some of which required hospitalization. this time he was too tired to go to the ER to seek medical help. His girlfriend found him shivering in fever at his friend's house and brought him to the ER. upon arrival to the ER, pt had elevated BP 170/90 , HR 110bmp, no heart murmur and Temp 101.2f, RR 18 and 98% on RA. appeared ill, erythema and swelling noted on his right arm with some Purulent discharge, tenderness and warmth. left thigh has similar presentation but wound was much bigger than the right arm. he also had swollen lymph nodes in his left inguinal area. 

briefly describe the following questions. looking for basic information for the answers. 

• What kind of diagnosis are you expecting? 

• What labs and diagnostic tests will the ER provider going to order? 

• What are the nursing priorities for this patient? 

Model Answer:

all the symptoms are pointing toward Staphylococcal infection which is common in individual who injects drugs. 

> the purulent drainage erythema, swelling and the patient's history of injecting drugs make this the most likely diagnosis. S.auresu, particularly MRSA is the leading cause of skin and soft tissue infections in individuals with history of injectable drugs. 

> cellulitis: although the erythema and swelling are consistent with cellulitis, but the presence of abscesses and pus formation makes a staph infection more likely. 

• expected labs and diagnostic tests: wound culture and sensitivity to rule out MSSA or MRSA. this will guide antibiotic therapy, CBC to check the WBC and elevated neutrophils, blood culture given the elevated fever and ultrasound to guide the I&D

• nursing priories:  monitor vital signs, monitoring the wound site, pain management , wound care and infection control and referral for addiction treatment. 

The Intention of the Question: 

this patient was admitted on my unit and stay on our unit for about three months until we found him an appropriate transportation to a different state where his parents lived. this was a young man who was 6 feet and 2 inch tall, he was morbid obese as well. around the clock pain medication. after the I&D his wound got further infected and ended up requiring wound vac to his left thigh. 

References

Parikh, M. P., Octaria, R., & Kainer, M. A. (2020). Methicillin-Resistant Staphylococcus aureus Bloodstream Infections and Injection Drug Use, Tennessee, USA, 2015-2017. Emerging infectious diseases, 26(3), 446–453.

Kievlan, D. R., Gukasyan, M., Gesch, J., & Rodriguez, R. M. (2015). Clinical profile of injection drug users presenting to the ED. The American journal of emergency medicine, 33(5), 674–676.

Model Answer:

Subungual melanoma is an uncommon yet potentially life-threatening type of skin cancer that develops beneath the nail, most often within the nail matrix. Its diagnosis is particularly challenging due to the intricate structure of the nail unit. A common early sign is longitudinal melanonychia, a dark stripe running down the nail. Because of this, healthcare providers should maintain a strong level of suspicion when this feature is present and consider biopsy early. One of the hallmark early indicators is pigmentation around the back of the nail fold. When a biopsy is warranted, it should be performed by a surgeon experienced in the specialized anatomy of the nail matrix and the characteristics of subungual melanoma.

When assessing a suspected skin malignancy on the upper extremity, it's essential to gather a thorough patient history, emphasizing both recent and remote changes in the lesion's size, appearance, and color. Melanomas can extend beyond their visible edges, which is especially relevant in subungual melanomas, where evaluating vertical margins is critical due to the minimal subcutaneous tissue separating the skin from deeper structures like the dermis and bone.

Additionally, many patients with subungual melanoma report a history of trauma to the affected area. While longitudinal melanonychia is often attributed to a hematoma, clinicians should not automatically make this assumption. Although nail trauma has been proposed as a possible cause of subungual melanoma, evidence does not support a direct link. However, such trauma can bring previously unnoticed melanomas to clinical attention.

The Intention of the Question: 

This experience happened to my daughter a year ago. We thought she probably injury her finger, so didn’t pay attention. Later, we noticed that black line still there even though new nail was continue growing. I started to search more information, then getting more concern and worry about the possibility for subungual melanoma. That was the reason I made appointment immediately with a dermatologist. We continue f/u a year and see if the black line gets winder or color change. Luckly, it stayed same, and it looked like just a benign molle in the nail. Recently, we found out the black line is gone.

This experience happened to my daughter almost 2 years ago. We initially thought she had probably injured her finger, so we didn’t pay much attention. Later, we noticed that the black line was still there even though new nail growth continued. I began researching and became increasingly concerned about the possibility of subungual melanoma. That’s when I decided to make an appointment with a dermatologist right away. We continued follow-up over the course of a year to monitor whether the line would widen or change in color. Fortunately, it remained the same, and it appeared to be just a benign mole in the nail. Recently, we discovered that the black line has disappeared.

References

DynaMedex (2023, Feburary 14). Nail disorders - approach to the patient. EBSCO Information Services. Accessed April 13, 2025. https://www.dynamedex.com/approach-to/nail-disorders-approach-to-the-patient 

Lipner, S. R., & Scher, R. K. (2016). Evaluation of nail lines: Color and shape hold clues. Cleveland Clinic Journal of Medicine, 83(5), 385–391. https://doi.org/10.3949/ccjm.83a.14187 

Littleton, T. W., Murray, P. M., & Baratz, M. E. (2019). Subungual melanoma. The Orthopedic Clinics of North America, 50(3), 357–366. https://doi.org/10.1016/j.ocl.2019.03.003 

Model Answer:

• 1) Digital clubbing is an indicator of an underlying systemic disease and is associated with a variety of respiratory and cardiovascular diseases, cirrhosis, colitis, and thyroid cancer (Ball, 2023, Ch 9, 133-188). 

Given this patient’s reports of exertional dyspnea and his history of smoking, he may have a pulmonary malignancy like lung cancer. Digital clubbing is associated with underlying medical conditions that reduce blood oxygen levels (Burcovschii & Aboeed, 2022). His SpO2 levels may not match his dyspnea, especially while he is at rest. 

• 2) The first priority would be to escalate the findings to the provider and document the presence of the digital clubbing and the patient’s reports of dyspnea. 

The second priority could be to advocate for further diagnostic workups, like a chest X-ray or CT or blood work.

An alternative priority would be patient education, including talking with the patient about how dyspnea and digital clubbing is not a normal change that comes with aging, and that it is advised that he receive further testing and workup to determine the cause of his dyspnea and digital clubbing. 

The Intention of the Question: 

The intention of this question is to challenge students to understand the underlying pathophysiology of disease processes. Although this is an integumentary finding, it is important to match this finding to its underlying cause. This question challenges students to recognize a physical assessment finding and ask what the potential causes of this finding are and then to think about the next steps in diagnosis and escalation of care. 

References

Ball, J., Dains, J., Flynn, J., Solomon, B., & Stewart, R. (2022). Chapter 9: Skin, Hair, and Nails. In Seidel's guide to physical examination (10th ed., pp. 133-188). Elsevier.

Burcovschii, S., & Aboeed, A. (2025). Nail clubbing. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK539713/ 

Question #16 by Jack Jorgensen

You are caring for a 17-year-old named Nigel who was referred to the ED by his PCP and ultimately admitted for enlarged lymph nodes and abnormal lab values with strong suspicion for lymphoma. Nigel is otherwise asymptomatic. On physical assessment you note palpable lymphadenopathy of left cervical supraclavicular nodes and right inguinal nodes. Biopsies from both sites confirm the presence of Reed-Sternberg Cells. 

Which type of lymphoma is characterized by the presence of Reed-Sternberg Cells? Why is this finding significant in establishing a diagnosis?  

Considering your nursing assessment of the lymph nodes, how would you expect Nigel’s lymphoma to be staged? How does the distribution of the affected lymph nodes affect staging for Nigel’s Diagnosis?   

Model Answer:

Reed-Sternberg (RS) Cells are the hallmark of Hodgkin’s lymphoma. RS cells are typically large and binucleate and are often described as having an owl eye appearance. The presence of RS cells is critical because it differentiates Hodgkin and Non-Hodgkin lymphomas which have different prognosis, staging, and treatment protocols. (5 pts)

Based on the Ann-Arbor Staging for Hodgkin lymphoma, Nigel has stage III because there is involvement of lymph nodes on both sides of the diaphragm. (5 pts) 

The intention of the question: 

Hodgkin Lymphoma (HL) is more common in adults, with a median age of diagnosis of 64, and accounts for only 7 percent of pediatric cancers. I chose this diagnosis because the signs, symptoms, and diagnostic criteria are the same regardless of age or gender, so it seemed to be more relevant to the whole class. 

The goal of this question is to have the learner relate Reed-Sternberg cells to the diagnosis of HL, and then apply knowledge of the Ann-Arbor scale to determine the clinical staging of the patient. 

References

McClean, K., Kamdar, K. (2022). Overview of Hodgkin lymphoma in children and adolescents. In Author(s) of the topic (Ed.), UpToDate. Retrieved April 13, 2025, from https://www.uptodate.com/contents/overview-of-hodgkin-lymphoma-in-children-and-adolescents 

Visovsky, C. G., Zambroski, C. H., & Lutz, R. M. (2023). Edmunds’ pharmacology for the primary care provider (5th ed., pp. 1023–1028). Elsevier.

Question #17 by Daysi Rodriguez 

Michael, a 24-year-old previously healthy male, presents to the ED with complaints of intermittent fevers over the past 3 weeks, significant night sweats that soak through his sheets, and unintentional weight loss of approximately 10 pounds. He reports feeling fatigued and describes a persistent, painless swelling in the left side of his neck that he noticed about a month ago. He denies recent travel, sick contacts, or drug use.

On physical exam, the nurse notes:

• Enlarged, firm, non-tender left cervical lymph node (approx. 2.5 cm)

• Pale skin tone

• Vitals: T 38.4°C (101.1°F), HR 98, BP 120/74, RR 18, SpO₂ 98% RA

• No signs of acute respiratory distress or hemodynamic instability

Past medical history is unremarkable. No known allergies. No current medications.

Initial nursing actions include:

• Vital signs monitoring

• Detailed health history and symptom review

• Preparing patient for labs (CBC, ESR, LDH) and imaging (chest X-ray/CT if ordered)

• Patient education and reassurance

What assessment findings and reported symptoms should lead the nurse to suspect Hodgkin’s Lymphoma in this patient, and what priority nursing actions should follow?

Model Answer:

Assessment Findings & Reported Symptoms Suggestive of Hodgkin’s Lymphoma:

• Painless cervical lymphadenopathy

• The enlarged, firm, non-tender left cervical lymph node is a hallmark of Hodgkin’s Lymphoma..

• B symptoms (systemic symptoms associated with lymphoma):

• Intermittent fevers

• Drenching night sweats

• Unintentional weight loss (10 lbs over 3 weeks is significant) These symptoms are characteristic and included in the diagnostic criteria for staging Hodgkin’s Lymphoma.

• Fatigue and pallor

• May reflect anemia or systemic disease burden.

• Age and presentation

• Hodgkin’s Lymphoma has a peak incidence in young adults (especially males in their 20s), matching this patient’s profile.

Priority Nursing Actions:

• Facilitate Diagnostic Workup:

  • Prepare and assist with labs:

    • CBC (to check for anemia, leukocytosis, or lymphocyte abnormalities)

    • ESR/LDH (elevated in malignancy/inflammation)

    • Possible peripheral blood smear

  • Chest X-ray or CT scan if ordered (to assess for mediastinal lymphadenopathy)

• Monitor for Disease Progression:

  • Continue to monitor vital signs, especially fever trends and signs of systemic involvement (e.g., respiratory changes if mediastinal nodes are involved).

• Symptom Management:

  • Keep the patient comfortable, hydrated, and reassured.

  • Offer education on possible causes of his symptoms, without causing alarm 

• Prepare for Specialist Referral:

  • Alert the provider to the high suspicion of lymphoma.

  • Ensure follow-up or referral to hematology/oncology.

• Emotional Support:

  • Acknowledge the patient’s fatigue and distress.

  • Provide emotional reassurance and support while maintaining clear, calm communication.

The Intention of the Question: 

This patient presents with classic features of Hodgkin’s Lymphoma: painless cervical lymphadenopathy and “B symptoms” (fever, night sweats, weight loss). The nurse’s role is crucial in identifying these red flags early, facilitating diagnostic workup, and providing holistic care—including physical and emotional support.

References

Cole, S., & Dunne, K. (2004). Hodgkin's lymphoma. Nursing standard (Royal College of Nursing (Great Britain) : 1987), 18(19), 46–55. https://doi-org.offcampus.lib.washington.edu/10.7748/ns2004.01.18.19.46.c3531 

Yung, L., & Linch, D. (2003). Hodgkin's lymphoma. Lancet (London, England), 361(9361), 943–951. https://doi-org.offcampus.lib.washington.edu/10.1016/S0140-6736(03)12777-8 

Question #18 by Jennifer Ofiana

A 29-year-old female presents to your clinic complaining of heart palpitations, weight loss, and heat intolerance. She states that despite having a bigger appetite than usual, she has lost 9 pounds in the last 5 weeks. The patient also states that her menstrual periods have become irregular and has difficulty sleeping. She denies recent travel, infections, and medication changes. You perform your physical assessment and find the following: 

• Vital signs: HR: 106 bpm, BP: 130/76 mmHg, Temp: 37.6°C/99.7°F

• Skin: Warm and moist

• Eyes: (+) mild exophthalmos

• Thyroid: Diffusely enlarged, non-tender, no nodules

• Hands: Fine tremor on outstretched hands

• (-) pregnancy test

Laboratory investigations requested by her physician revealed the following results:

Questions:

• 1. Describe how to properly examine the thyroid gland from behind.

• 2. What is the most likely diagnosis for this patient?

• 3. What medications are expected to be prescribed for this patient’s diagnosis (answer to question #1)? Please list at least one medication and rationale for giving this certain medication.

Model Answer:

• 1. Describe how to properly examine the thyroid gland from behind.

  • To examine the thyroid from behind, have the patient sit with their neck in a comfortable, neutral position. 

  • Place two fingers of each hand on either side of the trachea, just below the cricoid cartilage. 

  • Ask the patient to swallow while you palpate for movement of the isthmus. 

  • Next, gently shift the trachea to the left using the fingers of your right hand. 

  • With the first three fingers of your left hand positioned medial to the left sternocleidomastoid, palpate the left thyroid lobe as the patient swallows again. 

  • To examine the right lobe, reverse the hand positions and repeat the process (Ball, et al., 2023).

• 2. What is the most likely diagnosis for this patient?

  • The most likely diagnosis for this patient is hyperthyroidism, specifically Graves’ hyperthyroidism. 

• 3. What medications are expected to be prescribed for this patient’s diagnosis (answer to question #1)? Please list at least one medication and rationale for giving this certain medication.

  • Any of the following medications can be in used to answer this question:

    • Beta blockers ameliorate the symptoms of hyperthyroidism that are caused by increased beta-adrenergic tone (palpitations, tachycardia, tremulousness, anxiety, and heat intolerance). For symptom control, beta blockers are started (assuming no contraindications) as soon as the diagnosis is made. Atenolol has the advantage of single daily dosing and beta-1 selectivity; however, all beta-adrenergic blocking drugs effectively decrease hyperthyroid symptoms. 

    • Antithyroid drugs: To decrease thyroid hormone synthesis, all patients with overt hyperthyroidism (low TSH with elevated free thyroxine [T4] and/or triiodothyronine [T3]) due to Graves’ disease require additional treatment to decrease thyroid hormone synthesis. Treatment options for Graves’ disease include antithyroid drugs (thionamides), radioidodine, or surgery. Antithyroid drugs may be used initially to control hyperthyroidism before definitive treatment with radioiodine or surgery (to attain a euthyroid state preoperatively). The thionamide methimazole is the primary drug used to treat Graves’ hyperthyroidism because of its longer duration of action, allowing for once-daily dosing, more rapid efficacy, and lower incidence of side effects. 

    • Adjunctive therapies include:

      • a. Iodinated contrast agents and iodine: Sodium ipodate and iopanoic acid are potent inhibitors of the peripheral conversion of T4 to T3; when given in combination with methimazole, they can rapidly ameliorate severe hyperthyroidism. Iodine elixirs are used preoperatively to reduce gland vascularity.

      • b. Glucocorticoids: inhibit peripheral T4 to T3 conversion and in patients with Graves’ hyperthyroidism, reduce thyroid secretion. 

      • c. Cholestyramine: lowers serum T4 and T3 concentrations more rapidly than methimazole alone 

      • d. Lithium: blocks thyroid hormone release, but its used has been limited by its toxicity

      • e. Rituximab: a monoclonal antibody that caused peripheral B cell depletion, may induce a sustained remission in patients with Graves’ disease and low TSH-receptor antibodies levels

      • f. elemental calcium: Since hyperthyroidism results in a negative calcium balance, reduced bone density, and increased fracture risk, patients (except for those with hypercalcemia) should be advised to ingest 1200 to 1500 mg elemental calcium daily through diet or supplements when hyperthyroid

The Intention of the Question: 

Presenting a case of hyperthyroidism within the context of learning head and neck physical examination effectively bridges theory and clinical practice. It highlights key physical findings, reinforces anatomical landmarks such as the cricoid cartilage, trachea, thyroid isthmus, and lobes, and enhances diagnostic skills by allowing learners to correlate clinical signs with examination findings. 

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W., & Seidel, H. M. (2023). Seidel’s Guide to physical examination. Elsevier. 

Ross, D. (2024). Beta blockers in the treatment of hyperthyroidism. UptoDate. Retrieved April 14, 2025, from https://www-uptodate-com.offcampus.lib.washington.edu/contents/beta-blockers-in-the-treatment-of-hyperthyroidism?search=hyperthyroidism%20treatment&topicRef=7872&source=see_link#H4 

Ross, D. (2024). Graves’ hyperthyroidism in nonpregnant adults: Overview of treatment. UptoDate. Retrieved April 14, 2025, from https://www-uptodate-com.offcampus.lib.washington.edu/contents/graves-hyperthyroidism-in-nonpregnant-adults-overview-of-treatment?search=hyperthyroidism%20treatment&source=search_result&selectedTitle=2%7E150&usage_type=default&display_rank=1#H27895232 

Model Answer:

A basic overview of the function of lymph and lymph nodes will be helpful to this patient. The patient can be told the following: 

• The lymphatic system is an important part of the body’s immune system. This means that lymph and lymph nodes are critical parts of fighting infections. 

• Lymph is a fluid in the body that carries white blood cells – the cells that fight infections when you are sick. 

• Lymph nodes are small organs where white blood cells are made and stored. Lymph nodes are also cleaners – they filter lymph during times of infection. 

• Typically when you have an infection, the lymph nodes are working hard to make white blood cells to fight the infection and also to filter out any bacteria or other debris from the infection. 

• During this time, it is normal for lymph nodes to swell – that's why a doctor will touch your neck and throat to check for swelling. It’s a clue about a potential infection.

• If, however, your lymph nodes are swollen but you don’t have signs or symptoms of infection, then we want to rule out other possibilities that could be causing the lymph nodes to swell. 

• Your viral testing returned negative and your symptoms of a viral infection are vague and not consistent with the size of swelling we see near your neck. So now we’d like to use other diagnostic tools to help us figure out what’s going on. 

• An x-ray allows the doctor a visual picture of what’s going on inside your body so we can potentially identify other signs and symptoms of what’s happening to cause this swelling. 

The Intention of the Question: 

The intention of this question is to ask the student nurse to critically think about possible etiologies of swollen, palpable lymph nodes and the diagnostic tools that could be used to assess the patient. The question also asks the student nurse to then take this knowledge and translate it into education for the patient in a way that is easy to follow and understand. 

References

Null, M., Arbor, T.C., & Agarwal, M. (2023, March 6). Anatomy, lymphatic system. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK513247/ 

Stoler, N.A. & Chelius D.C (2024, September 12). Enlarged lymph nodes. JAMA Otolaryngology - Head and Neck Surg,150(11):1045. doi:10.1001/jamaoto.2024.2686

Question #20 by Muskan Priya

You are a case manager for Mr. Jefferson, 75-year-old male. He went to urgent care with complaints of abdominal pain that has last about 3 months. He reports experiencing nausea intermittently throughout the day and has had several on and off episodes of a UTI in the past months. His past medical history is significant for metastatic melanoma, with known lymph node involvement. He denies any vomiting but has been having changes in his bowel movements and a decrease in his appetite. He appears fatigued and has shared that he is emotional drained.

In his assessment findings, his abdomen is tender in the lower quadrants, no rebound tenderness and mild distension. 

As the nursing case manager for Mr. Jefferson and meeting him every other week, place the following nursing actions in order of priority? Explain rationale.

• A. Educate the patient about dietary changes to reduce nausea and improve appetite

• B. Notify the provider about the persistent abdominal pain and recurrent UTIs 

• C. Administer anti-nausea medication as prescribed

• D. Encourage fluid intake to prevent further urinary tract infections

Model Answer:

B, C, D, A – It is important to notify the provider of these changes because this can lead to cancer progression, obstruction or other complications that need to be evaluated and can’t be evaluated in urgent care. Try to manage the client’s discomfort, help reduce his recurrent UTI, education the patient on dietary changes to help alleviate any pain/discomfort with food. Also, wanting to make sure that client has enough nutrition. 

The Intention of the Question: 

The intention of this question was based off my older client that I work for and do home visits at. For the past three months, he wasn’t feeling well. There were many home remedies that were tried were helpful for a little bit but not a long time. Finally, after going to the ED at UW, he was able to get scans and work up done, which showed he had malignant melanoma. He is getting immunotherapy for his cancer.

References

Mayo Foundation for Medical Education and Research. (2023, December 30). Melanoma. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/melanoma/symptoms-causes/syc-20374884 

NCI Staff., Melanoma cells that pass through lymph more likely to spread. Melanoma Cells that Pass through Lymph More Likely to Spread. https://www.cancer.gov/news-events/cancer-currents-blog/2020/melanoma-spread-lymph-nodes-ferroptosis