Question #1 by Daysi Rodriguez 

Exercise-Induced Asthma in an 8-Year-Old

Patient Profile:

• Name: Ethan Smith

• Age: 8 years old

• Gender: Male

• Grade: 3rd

• Medical History: Mild intermittent asthma diagnosed at age 6

• Medications: Albuterol inhaler as needed

• Allergies: None known

• Family History: Mother has asthma, father has seasonal allergies

Scenario Description:

Ethan is brought to the school nurse's office after physical education class. He is experiencing shortness of breath, wheezing, and mild chest tightness. His symptoms started during a game of tag and worsened after running for several minutes. He reports using his albuterol inhaler that morning but did not bring it to school today.

As the nurse, you assess Ethan’s respiratory status, which includes:

• Respiratory rate: 26 breaths per minute

• Audible wheezing

• Oxygen saturation: 95% on room air

• Slight use of accessory muscles

• Speaking in full sentences, though mildly distressed

You assist Ethan with controlled breathing, notify the parents, and advise they bring his inhaler immediately. You also initiate a referral for follow-up care with his pediatrician to assess his asthma action plan and determine the need for long-term control medication.

• 1) What steps should a school nurse take when a child presents with exercise-induced asthma symptoms during physical activity?

• 2) What are key indicators that the asthma is not well-controlled in this child?

Model Answer:

When a child presents with exercise-induced asthma (EIA) symptoms, the school nurse should promptly assess and manage the situation to prevent worsening respiratory distress:

• 1. Immediate Assessment: Check the child's airway, breathing, and circulation (ABCs). Measure respiratory rate, oxygen saturation (SpO₂), and listen for wheezing or use of accessory muscles.

• 2. Administer Quick-Relief Medication: If the child has an asthma action plan and a quick-relief inhaler (usually albuterol), assist in administering it using a spacer if available (National Heart, Lung, and Blood Institute .

• 3. Calm Environment: Have the child sit upright and encourage slow, controlled breathing in a quiet, calm environment to reduce anxiety, which can worsen symptoms.

• 4. Monitor Response: Observe the child’s response to the medication for 10–15 minutes. Recheck respiratory status, including rate, ease of breathing, and oxygen saturation.

• 5. Notify Parents/Guardians: Inform them about the episode and recommend follow-up with the child’s healthcare provider, especially if episodes are recurring or worsening.

• 6. Documentation and Follow-up: Document the incident in the child’s health record and recommend revisiting or updating the asthma action plan).

2. What are key indicators that the asthma is not well-controlled in this child?

• 1. Frequent Symptoms: Ethan is experiencing asthma symptoms during regular physical activity, which should be manageable if the asthma is well-controlled 

• 2. Inhaler Not Readily Available: He did not bring his rescue inhaler to school, indicating a possible gap in self-management education or oversight by caregivers 

• 3. Use of Quick-Relief Inhaler Prior to Activity: Routine pre-exercise inhaler use without an underlying long-term controller medication might indicate under-treatment of persistent symptoms 

• 4. Exercise Limitation: If physical activity regularly triggers symptoms, this limits participation in normal childhood activities and is a hallmark of uncontrolled asthma 

• 5. Family History: Given his mother has asthma, there is a genetic predisposition, and more proactive management might be necessary to prevent symptom escalation 

The Intention of the Question: 

Exercise-induced asthma (EIA) is common in kids, but it often flies under the radar because they might not speak up about their symptoms—or they just steer clear of things like running or playing that bring it on (Massie, 2002). Nurses play a key role here. Their main goal is to help kids learn how to manage their asthma, stay safe while being active, and avoid asthma flare-ups. One of the best tools for this is a personalized asthma action plan. These plans help kids, and their families know when and how to use medication, spot early warning signs, and know what to do in an emergency. It gives them the confidence to handle asthma day-to-day. Still, a lot of people struggle with keeping asthma under control, and that often means kids missing school, parents missing work, and more trips to the ER or even the hospital (Lang, 2019).

References

Centers for Disease Control and Prevention. (2022). Asthma in schools. https://www.cdc.gov/healthyschools/asthma/index.htm 

Global Initiative for Asthma. (2023). GINA report: Global strategy for asthma management and prevention. https://ginasthma.org 

National Heart, Lung, and Blood Institute. (2020). Asthma care quick reference: Diagnosing and managing asthma. U.S. Department of Health and Human Services. https://www.nhlbi.nih.gov 

Massie J. (2002). Exercise-induced asthma in children. Paediatric drugs, 4(4), 267–278. https://doi-org.offcampus.lib.washington.edu/10.2165/00128072-200204040-00006 

Lang J. E. (2019). The impact of exercise on asthma. Current opinion in allergy and clinical immunology, 19(2), 118–125. https://doi-org.offcampus.lib.washington.edu/10.1097/ACI.0000000000000510 

Question #2 by Hannah Pankratz

A 17-year-old male presents to the emergency department with increasing dyspnea over the last several days. He recently returned to the area after flying to an out of state basketball tournament. He describes some chest pain on the right side, rates it a 7/10 and describes it as sharp. Vital signs are WNL except for heart rate of 110 at rest and respiratory rate of 24, SpO2 at 92%. Chest xray is obtained, and the patient has a tension pneumothorax.

What treatment would you expect in the setting of a tension pneumothorax?

What assessment findings would you, as the nurse, expect to see as the patient improves?

Model Answer:

In this case, the patient would be admitted to an inpatient unit and have a chest tube placed on the right side to manage the tension pneumothorax (Dynamedex, 2025). The nurse should also place the patient on oxygen, establish IV access, and initiate cardiac monitoring (Dynamedex, 2025). 

In monitoring the patient and assessing him as he improves, the nurse should expect to see that the air leak in the chest tube continues to decrease, the tachypnea and tachycardia return to within normal limits, pain decreases, oxygenation improves to within normal limits and supplemental oxygen is discontinued, and eventually the chest tube is able to be discontinued without recurrence of pneumothorax (Huggins et al., 2024). 

The Intention of the Question: 

The intention of this question is to identify a common way that pneumothoraxes are treated in the hospital setting, as well as to identify assessment findings that would be reassuring to the nurse that the patient is continuing to improve with the treatment plan.

References

DynaMedex. Spontaneous pneumothorax in adults. EBSCO Information Services. Accessed April 27, 2025. https://www-dynamedex-com.offcampus.lib.washington.edu/condition/spontaneous-pneumothorax-in-adults#GUID-303227A6-B8EA-4ECE-98E1-360E10F21F54 

Huggins, J., Carr, S., & Woodward, G. (2024). Thoracostomy tubes and catheters: Management and removal. UpToDate. Retrieved April 28, 2025, from https://www-uptodate-com.offcampus.lib.washington.edu/contents/thoracostomy-tubes-and-catheters-management-and-removal?search=chest%20tube&source=search_result&selectedTitle=2%7E150&usage_type=default&display_rank=2 

Model Answer:

Interpret this ABG and calculate the P/F ratio.

ABG: Uncompensated mixed respiratory and metabolic acidosis with hypoxemia and hypoxia (Brashers & Huether, 2019)

P/F ratio = PaO2 / FiO2 percentage (Siegel, 2019)

P/F ratio = 54/1 = 54 mmHg 

Provide a short rationale for why the provider might ask you to prepare Laura for intubation based on your assessment findings and interpretation of Laura’s ABG and P/F ratio.

In the initial assessment Laura is showing signs of progressively worsening respiratory distress. Her accessory and abdominal muscle use, productive cough, lung sounds, and oxygen requirements are all indicative of respiratory failure, and if the team does not intervene, she is at high risk of respiratory arrest (Brashers & Huether, 2019). Additionally, Laura indicates that she is starting to tire out, and her report of distress should be enough to prompt concern and further intervention. Her arterial blood gas shows severe metabolic and respiratory acidosis with hypoxemia and hypoxia which will result in respiratory arrest if left untreated (Siegel, 2024). The P/F ratio is a diagnostic measure used to determine the severity of hypoxemia in ARDS patients. A P/F ratio of <100 indicates severe ARDS and without mechanical ventilation she will likely decompensate and die from her condition (Siegel, 2024).

What nursing interventions do you expect after intubation? Select all the apply.

Answer: A, C, & D

Rationale (not required by the student)

A - Laura will require sedation and pain management to be able to tolerate the ventilator. Mechanical ventilation is uncomfortable and painful, so it is important to administer pain medication in addition to a sedative. Ventilator desynchrony is common in patients with ARDS, and can result in patient distress, frequent alarms, and ineffective mechanical ventilation. Sedation and pain management will allow Laura to rest and keep the ventilator working appropriately (Siegel & Siemieniuk, 2025).

B – Suctioning of the endotracheal tube should always be performed when clinically indicated, not on a routine schedule. Over-suctioning the patient can cause trauma to the airway. Clinical signs that indicate that suction is necessary include desaturation, crackles/rhonchi, coughing, agitation, and high-pressure ventilator alarms, although an alarm alone is not indicative of a need for suctioning (Hare & Seckel, 2023).

C – Prone positioning can improve oxygenation by removing the pressure of the heart from the lungs and allowing the alveoli of the posterior lobes to re-inflate. This addresses the ventilation/perfusion mismatch that occurs with ARDS and allows for improved gas exchange. While proning is a complicated procedure, it is minimally invasive, and for someone like Laura with a severely low P/F ratio proning is shown to reduce mortality. She does not have any contraindications to the procedure and with the severity of her disease it is likely that she will be proned (Malhotra, 2025). 

D – Nutritional support will provide support for Laura’s immune system, assist with cellular repair, and help with the metabolic stress response associated with ARDS. Even if she is proned enteral nutrition is an important aspect of caring for critically ill people and will improve her outcomes should she survive her acute illness. If Laura becomes hemodynamically unstable, nutrition should be postponed (Siegel & Siemieniuk, 2025). 

The Intention of the Question: 

I have cared for many patients like Laura throughout my career both pre and post COVID. My intention for this question is to encourage the student to think about the mechanics of respiration, gas exchange, and how respiratory illnesses like pneumonia can impair this essential process. Additionally, I wanted the student to think about the common nursing interventions for a patient who has just been intubated. While the main portion of the question is not about proning, I wanted to touch on how proning can be a minimally invasive, but effective, nursing intervention for patients with ARDS.

References

Brashers, V. L., & Huether, S. E. (2019). Alterations of pulmonary function. In V. L Brashers & N. S. Rote (8th Eds.), Pathophysiology: The biologic basis for disease in adults and children (pp. 1163-1201). El Sevier.

Hare, E. & Seckel, M. A. (2023). Suctioning: Endotracheal or tracheostomy tube. In K. L. Johnson (8th Eds.), AACN procedure manual for progressive and critical care (pp. 76-84). El Sevier.

Malhotra, A. (2025, April 23). Acute respiratory distress syndrome: Prone ventilation in adults. UpToDate. Retrieved April 28, 2025, from https://www.uptodate.com/contents/acute-respiratory-distress-syndrome-prone-ventilation-in-adults?search=prone%20positioning&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#H3548698186 

Siegel, M. D. (2024, November 21). Acute respiratory distress syndrome: Clinical features, diagnosis, and complications in adults. UpToDate. Retrieved April 28, 2025, from https://www.uptodate.com/contents/acute-respiratory-distress-syndrome-clinical-features-diagnosis-and-complications-in-adults?search=ARDS&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#H979970613 

Siegel, M. D., & Siemieniuk, R. (2025, January 29). Acute respiratory distress syndrome: Fluid management, pharmacotherapy, and supportive care in adults. UpToDate. Retrieved April 28, 2025, from https://www.uptodate.com/contents/acute-respiratory-distress-syndrome-fluid-management-pharmacotherapy-and-supportive-care-in-adults?search=paralytics%20ARDS&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#H6 

Model Answer:

Risk factors for developing TB include the following: recent residence in an endemic region, low socioeconomic status, ethnic minorities, homelessness, close contact to known case of TB, institutional living or employment at high-risk facilities (e.g., correctional facilities, homeless shelters, skilled nursing facilities), health care employment, elderly or very young patients, and immune suppression. Common presenting symptoms include fever, productive cough, dyspnea, night sweats, malaise, fatigue and weight loss, hemoptysis, and pleuritic chest pain. Isolation within a negative pressure room should be done as early as possible for those suspected of having TB. Treatment should not be initiated before consulting with hospital infectious disease specialists. As this is a reportable disease, public health services should be notified of all suspected and confirmed cases. Given the frequency of co-infection with HIV, patients identified as having active TB should receive counselling and HIV testing. Contact primary care physicians or public health services and arrange for long-term care before patient discharge. Discharge instructions include home isolation procedures and follow-up at the appropriate clinic to receive medication and ongoing care. Antituberculosis medications should not be instituted in the ED unless there is joint agreement with the consultant and follow-up providers. Prior to commencing therapy, baseline labs are recommended as follows: CBC (platelet count), LFTs, serum urea, and creatinine (Belle & Wise, 2017).

Early diagnosis and successful treatment of TB is crucial to prevent further spread of the bacteria and development of resistant strains. Several diagnostic techniques are commonly employed, including immunological, radiographical, microscopical, bacterial culture and clinical methods. Immunological tests, such as QuantiFERON-TB Gold (QFT) and Tuberculin skin test (Mantoux test) are mainly used for the purpose of screening and ruling out TB infection. Similarly, radiography (Chest X-rays) is a screening tool used to diagnose active pulmonary TB; however, it cannot help in detecting latent TB infection. Sputum smear microscopy is a very efficient and widely used tool in TB diagnosis, in which the TB bacteria are stained with Ziehl–Neelsen stain, but low sensitivity and lack of differentiation between M. tb and other acid-fast bacilli are key caveats of this method. Unlike smear spectroscopy, sputum culture is a highly specific and sensitive diagnostic TB method wherein Löwenstein–Jensen medium is used to culture the TB bacteria. However, since M. tb is a slow-growing organism, it takes at least two weeks (sometimes 6–8 weeks) for the colonies to appear, which further delays the diagnosis and treatment. Finally, in 5–10% of TB-infected individuals, several signs and symptoms develop, which allow for clinical diagnosis. The clinical manifestations of active pulmonary TB may include pleuritic chest pain, low-grade fever, prolonged productive cough, hemoptysis, fatigue, loss of appetite, night sweat and weight loss (Alsayed & Gunosewoyo, 2023).

The Intention of the Question: 

TB is caused by bacteria (Mycobacterium tuberculosis) and it most often affects the lungs. TB is spread through the air when people with lung TB cough, sneeze or spit. A person needs to inhale only a few germs to become infected. Every year, 10 million people fall ill with tuberculosis (TB). Despite being a preventable and curable disease, 1.5 million people die from TB each year – making it the world’s top infectious killer. TB is the leading cause of death of people with HIV and also a major contributor to antimicrobial resistance. Most of the people who fall ill with TB live in low- and middle-income countries, but TB is present all over the world. About half of all people with TB can be found in 8 countries: Bangladesh, China, India, Indonesia, Nigeria, Pakistan, Philippines and South Africa (World Health Organization, 2025). 

The number of reported tuberculosis (TB) disease cases and incidence rate increased in 2023 for the third year since 2020, surpassing pre-COVID-19 pandemic levels (CDC, 2023). 

US is a melting pot of cultures and is one of the most visited countries in the world, the chance is high to receive visitors or patients coming from TB-endemic regions or countries, having the knowledge on TB, its course of treatment and most especially its isolation precautions will help reduce the rates of its transmission.

References

Alsayed, S. S. R., & Gunosewoyo, H. (2023). Tuberculosis: Pathogenesis, Current Treatment Regimens and New Drug Targets. International journal of molecular sciences, 24(6), 5202. https://doi.org/10.3390/ijms24065202 

Belle, T. & Wise, A. (2017, September 06). Tuberculosis: Presentation and ED Management. EMDOCS. https://www.emdocs.net/tuberculosis-presentation-ed-management/ 

CDC. (2023). Reported Tuberculosis in the United States, 2023. https://www.cdc.gov/tb-surveillance-report-2023/summary/national.html 

WHO. (2025). Tuberculosis. https://www.who.int/health-topics/tuberculosis#tab=tab_3 

Question #5 by Hillary Viswanathan

You are a circulating nurse in the operating room training a nurse new to the OR. At the beginning of the day, a huddle occurs between you, the surgical technologist, the surgeon, and the anesthesia provider during which the specifics of each case are discussed. During the huddle the anesthesia provider informs the team that she is planning to use an LMA for the first two cases and an ET tube for the third case. You make note of this information. 

After the huddle, your orienting nurse asks you several questions:

• 1. What is an LMA?

• 2. The anesthesia provider is using an LMA for two cases but an ET tube for the third. Why doesn’t she use an LMA for all three cases? 

  • a. Hint for #2: You don’t need to know the specifics of the patient. Please identify 3 parameters that would guide the anesthesia provider’s decision for selecting an appropriate device for establishing and maintaining the airway during surgery and provide one example of a patient condition that would dictate this choice. 

*BONUS: As the nurse assisting the anesthesia provider with establishing an airway prior to surgery, identify 2 things you could assess to confirm the airway device is placed correctly. 

Model Answer:

1. A laryngeal mask airway (LMA) is a supraglottal device inserted into the pharynx and rests at the opening of the trachea with the tip at the esophageal inlet (Doyle, 2025). This is different from an endotracheal tube which would be inserted fully into the trachea (Hayek Medical, n.d.). For visual learners, an image of the LMA in correct placement would be helpful, such as the following:

2. LMAs are helpful devices for establishing and maintaining a patent airway but only for specific patients and surgical cases. Generally speaking, LMAs are appropriate for cases of short duration (around 3 hours or less), for patients who are at low risk for aspiration, and for surgical cases that do not require muscle relaxation (Berkow, 2024). LMAs will not protect against aspiration or laryngospasm and can only be used with lower peak inspiratory pressures but may be easier to place and have a lower risk for bronchospasm or hemodynamic response than an ET tube (Berkow, 2024). Therefore patient comorbidities and the surgery being performed must be evaluated in order to select an appropriate airway device (Berkow, 2024). For example, patients with uncontrolled and significant GERD have a high risk of aspiration and would not be a candidate for an LMA (Berkow, 2024). 

BONUS: Once the LMA or ET tube is placed, the assisting nurse can ensure proper placement by any of the following:

• 1. Able to effectively ventilate manually

• 2. Chest rise with symmetry

• 3. Able to visualize condensation on the tube of the device

• 4. Appropriate ETCO2 waveform reading (Berkow, 2024)

The Intention of the Question: 

The question asks the student nurse to identify various airway devices used during surgery and demonstrate knowledge of how they work. The question also asks the nurse to apply critical thinking regarding contraindications for airway devices and key patient assessment findings that will guide the team’s decision for an appropriate airway device. The bonus question asks the student nurse to apply their knowledge to patient assessment. 

References

Berkow, L.C. (2024, October 30). Airway management for general anesthesia in adults. UpToDate. Retrieved April 27, 2025, from https://www-uptodate-com.offcampus.lib.washington.edu/contents/airway-management-for-general-anesthesia-in-adults?sectionName=Choice%20of%20airway%20device&search=laryngeal%20mask%20airway%20versus%20endotracheal%20tbe&topicRef=98733&anchor=H717871230&source=see_link#H717871230 

Doyle, D.J. (2025, January 14). Supraglottic airways (SGAs) for airway management for anesthesia in adults. UpToDate. Retrieved April 27, 2025, from https://www-uptodate-com.offcampus.lib.washington.edu/contents/supraglottic-airways-sgas-for-airway-management-for-anesthesia-in-adults?search=laryngeal%20mask%20airway%20versus%20et%20tube&source=search_result&selectedTitle=5%7E150&usage_type=default&display_rank=5 

Hayek Medical (n.d.). Endotracheal intubation complications and risks. https://hayekmedical.com/2025/01/06/endotracheal-intubation-complications-and-risks/ 

Question #6 by Erin Woods

You are a nurse working in the cardiac ICU who is responsible for admitting a neonate after they failed their routine critical congenital heart disease screening. They are receiving prostaglandin (PGE) until they have cardiac surgery. As you hook the baby up on monitors, the family notices that you’ve placed two oxygen saturation probes on their baby, and that the numbers are different from each other.  They ask you to explain the discrepancy. What would you say to the family about the rationale for obtaining oxygen saturation measurements in two different places? Include in your answer:

• The placement of the two sat probes and why that placement is important.

• The pathophysiology of heart defects that would require this monitoring.

Model Answer:

The two sat probes are measuring pre and post ductal sats on the infant. The baby has a congenital heart defect which may be ductal dependent and causing right to left shunting (Slota, 2006). A ductal dependent lesion means that it is necessary for the ductus arteriosus to remain patent until the heart defect is repaired in order for the heart to receive oxygenated blood to deliver to the body because there is some obstruction to the outflow of blood from the left ventricle to the body (Slota, 2006). The ductus arteriosus connects the pulmonary artery to the aorta in fetal circulation. By keeping the ductus arteriosus patent, the baby’s blood can be “mixed” until surgery. One sat probe would be placed on the right hand, measuring preductal sats (oxygenated blood) and the other would be placed on the left hand or foot and used to measure postductal sats, which is mixed blood, measuring the amount of oxygen that is being delivered systemically (Newborn Screening Ontario, 2025). 

Grading rubric will be looking for:

• 1. Correct placement of sat probes

• 2. Rationale for placement

• 3. An explanation that the baby likely has a ductal dependent lesion and needs a PDA (patent ductus arteriosus) in order to survive until surgery. 

• 4. Explanation of blood mixing leading to the different sat measurements

• 5. APA formatting

The Intention of the Question: 

The intention is for students to recognize the complexities of congenital cardiac defects and how the lesions can affect systemic oxygenation. By recognizing the importance of maintaining a patent ductus arteriosus and monitoring for its patency nurses can understand both the life-threatening implications of premature closure of ductus arteriosus and what happens when the normal flow of blood through the heart and lungs is obstructed. 

References

Newborn Screening Ontario. (2025). Pulse oximetry protocols: Critical congenital heart disease (CCHD). Newborn Screening Ontario. https://submitterhub.newbornscreening.on.ca/critical-congenital-heart-disease-cchd/pulse-oximetry-protocols/ 

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

Question #7 by Jack Jorgensen

You are caring for a 14-year-old boy named Ivan who appears to the Emergency Department reporting palpations, chest discomfort, fatigue, and light headedness. Ivan started feeling this way during his basketball game, from which his parents took him straight to the hospital. On assessment, Ivan appears pale, diaphoretic, and anxious. 

• HR:208 bmp

• BP: 94/64

• RR: 18

• Temp: 36.8

Based on the patient history and assessment findings, which cardiac arrhythmia so you suspect? 

After 30 minutes in the ED, Ivan’s blood pressure drops to 78/52 and he has decreased level of consciousness. What pharmacological intervention do you anticipate? What administration considerations do you have for this medication?

Model Answer:

Ivan is showing signs and symptoms of Supraventricular Tachycardia (SVT) (4 points). SVT is the most common arrythmia in children, most of whom have structurally normal hearts (Dubin, 2023) 

There are some non-pharmacological interventions that can be used for patients with SVT who are hemodynamically stable, that typically evoke a vagal response (ie. Blowing through a straw, icepack to the face). Since Ivan is demonstrating hemodynamic instability, I would anticipate an order for Adenosine (3 points). This should be administered via rapid IV push through a large proximal vein, as close to central circulation as possible, followed by a rapid saline flush using a three-way stopcock. (3 points) (Lewis et al. 2017).

Bonus info: Cardioversion is the definitive treatment for SVT for children who are hemodynamically unstable. Technically, it should not be delayed for non-pharmacological interventions or the administration of adenosine, though those interventions are often done before cardioversion as they are less invasive and usually not difficult administer (depending on hemodynamic status) (Dubin, 2023).

The Intention of the Question: 

Non-congenital cardiac conditions are relatively rare in pediatrics. Prolonged SVT is a common emergency, though it is often responsive to non-pharmacological intervention and rarely does it progress to hemodynamic instability. I have only given Adenosine once for this condition, though it was memorable. 

I am hopeful that this question requires the learner to recognize the signs and symptoms of SVT. I wanted the learner to recognize the condition without an ECG strip. 

I also wanted to review the administration of Adenosine since it is critical to the effectiveness of the medication in treating SVT. 

References

Dubin, A. M. (n.d.). Clinical features and diagnosis of supraventricular tachycardia (SVT) in children. UpToDate. Retrieved April 27, 2025, from https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-supraventricular-tachycardia-svt-in-children 

Lewis, J., Arora, G., Tudorascu, D. L., Hickey, R. W., Saladino, R. A., & Manole, M. D. (2017). Acute management of refractory and unstable pediatric supraventricular tachycardia. The Journal of Pediatrics, 181, 177–182.e2. https://doi.org/10.1016/j.jpeds.2016.10.051 

Model Answer:

Based on Jenny’s symptoms and VS, she most likely has postural orthostatic tachycardia syndrome (POTS). This condition is diagnosed with the tilt-table test (Gelfand et al., 2024). To help manage her symptoms, Jenny can make the following lifestyle changes (Cheshire, 2024):

• Increase her sodium intake to at least 3 grams a day and ensure proper hydration (aim for 3 L of fluids per day)

  • Rationale: Doing these together can help artificially increase the patient’s blood volume, which can help reduce their symptoms

• Wear compression garments when possible

  • Rationale: This prevents venous pooling in the lower extremities which can help prevent dips in blood pressure

• Partake in semi-recumbent aerobic exercise such as swimming or utilization of a rowing machine/recumbent bike

  • Rationale: Deconditioning can increase the severity of POTS symptoms, and exercising in a non-standing position can help limit the risk of symptoms increasing while exercising

Bonus: When a person has POTS, their symptoms are caused by at least one of the following physiologic mechanisms:

• Hypovolemia: Most POTS patients have reduced intravascular volume which makes it such that their hearts must beat faster to maintain adequate blood pressure. This may be the result of inadequate renal sodium retention secondary to low aldosterone levels and plasma renin activity. Some patients with POTS have suspected inadequate angiotensin-converting enzyme 2 activity, as suggested by elevated plasma levels of angiotensin II (Bryarly et al., 2019). The fatigue and exercise intolerance seen in the condition can lead to deconditioning, which only exacerbates the problem due to the heart needing to beat even faster to sustain cardiac output (Cheshire, 2024).

• Neuropathy: Sympathetic denervation prevents vascular constriction during postural changes, which allows blood to pool in the lower extremities and splanchnic vasculature. To compensate for this, cardiac output must increase which leads to increased heart rate (Gelfand et al., 2024).

• Neuroendocrine: Some patients with POTS may be in a hyperadrenergic state, as suggested by increased cardiovascular adrenergic activity which is separate from tachycardia. When compared to people without POTS, these individuals tend to have increased plasma levels of catecholamines, which may be due to a deficiency in the norepinephrine transporter. This results in increased plasma levels of norepinephrine when standing, which causes the orthostatic tachycardia and other symptoms seen in the condition (Bryarly et al., 2019).

The Intention of the Question: 

This question is based on me. POTS isn’t something that I’ve heard discussed widely, and it can cause some pretty debilitating symptoms in those that have it. I also find it super interesting that for myself, and others with the condition, the amount of sodium we need each day for our bodies to function properly is well beyond what someone without the condition can have without their blood pressure increasing significantly. 

References

Bryarly, M., Phillips, L. T., Fu, Q., Vernino, S., & Levine, B. D. (2019). Postural Orthostatic Tachycardia Syndrome: JACC Focus Seminar. Journal of the American College of Cardiology, 73(10), 1207–1228. https://doi-org.offcampus.lib.washington.edu/10.1016/j.jacc.2018.11.059 

Cheshire, W. (2024, October 10). Postural tachycardia syndrome. UpToDate. https://www.uptodate.com/contents/postural-tachycardia-syndrome?search=pots&source=search_result&selectedTitle=1%7E60&usage_type=default&display_rank=1#H240758182 

Gelfand, E., Jolanda van Zuuren, E., Oettgen, P. (Eds.). (2024, July 11). Postural tachycardia syndrome (POTS. DynaMedex. https://www-dynamedex-com.offcampus.lib.washington.edu/condition/postural-tachycardia-syndrome-pots 

Model Answer:

• 1. The probable diagnosis is Tetralogy of Fallot (TOF). The nurse should anticipate that the patient will be referred to specialty Maternal Fetal medicine and getting a ECHO. 

• 2. The new born will become hypoxic and cyanotic, a systolic murmur will be heard, difficulty feeding resulting in failure to thrive, 

• 3. Managing hypercyanotic episodes, O2, propranolol, new to chest positioning, calming child. Will need surgery to correct defects. 

The Intention of the Question: 

The intent of the question is to elicit critical thinking from beginning to end of the patient with TOF.

References

Ball, J. W., Binder, R. C., Cowen, K. J., & Shaw, M. C. (2012). Principles of Pediatric Nursing: Caring for Children (5th ed.). Pearson Education, Inc.

Lee, W., Smith, R. S., Comstock, C. H., Kirk, J. S., Riggs, T., & Weinhouse, E. (1995). “Tetralogy of Fallot: Prenatal Diagnosis and Postnatal Survival.” Obstetrics and Gynecology, 86(4 Pt 1), 583–588. https://doi.org/10.1016/0029-7844(95)00245-m 

Model Answer:

Peter’s diagnosis is bacterial endocarditis as evidenced by the vegetation found on the mitral valve of his heart during his TEE. Additionally, he is showing signs of endocarditis, such as shortness of breath, dyspnea on exertion, fatigue, fever, and murmur, which are all symptoms associated with bacterial endocarditis (Ball et al., 2023). Peter is likely to be started on an antibiotic regimen such as vancomycin and cefepime (Elsevier ClinicalKey, 2025). Once blood cultures return, the antibiotic regimen can be adjusted to target the specific bacterial infection (“antibiotics” is an acceptable answer). Complications that could potentially arise include congestive heart failure, abscess, pseudoaneurysm, fistula, perforation, atrioventricular block, and other malignant arrhythmias, myocarditis, pericarditis, pericardial effusion, septic embolization involving brain, spleen, extremities, and mesenteric area, renal impairment, and sudden death (Elsevier ClinicalKey, 2025). 

Points:

• Diagnosis: 2 points

• Medication: 2 points

• Complications: 2 points for each listed (no bonus points for listing more)

The Intention of the Question:

This is a scenario happened to me when I was a new graduate nurse. This patient presented in the Emergecny Department and was then directly admitted up to my unit. He presented for a completely different reason, but we incidentaly found a major health concern for this patient. This patient was in the hospital for at least a month if I remember correctly. During that time a lot of education was provided, and he abstained from drug use during that time. Due to this patient’s poor health history, it was unclear if most of the cardiac diagnose he discharged with were present before or after his endocarditis. 

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 (10th ed.). Elsevier.

Cabell, H., Abrutyn, E., & Karchmer, A. (2003). [Photograph bacterial endocarditis]. American Heart Association/American Stroke Association. https://www.ahajournals.org/cms/10.1161/01.CIR.0000071082.36561.F1/asset/b3dce8d7-371f-4dc0-ab8d-141381292423/assets/graphic/1ff1.jpeg 

Elsevier ClinicalKey. (2025, March 23) Endocarditis. Retrieved April 26, 2025 from https://www.clinicalkey.com/#!/content/clinical_overview/67-s2.0-6595b049-af05-4de9-a46a-57cb2c386b9d#complications-and-prognosis-heading-39 

Model Answer:

• 1. This patient has atrial fibrillation (AFib), an abnormal heart rhythm caused by the atria beating irregularly or rapidly, causing the atria to quiver rather than contract forcefully (Banasik & Copstead, 2018). 

• 2. To treat and convert this patient out of Afib, you would want to give a B1-selective blocker such as metoprolol, atenolol, or bisoprolol. Beta 1 selective blockers help treat Afib by blocking the stimulation of beta1 receptors in the heart (Hazard Vallerand & Sanoski, 2019). Blocking this receptor prevents adrenaline and norepinephrine (hormones) from stimulating the heart and causing it to contract. This causes the heart rate to slow and reduces the number of contractions done by the heart, therefore converting the patient out of Afib (Hazard Vallerand & Sanoski, 2019). 

• 3. Many different types of patient education can be provided to this patient. Some examples are below. 

  • a. Though this patient did not initially have symptoms, some they should be aware of include heart palpitations, tachycardia, fatigue, dizziness, weakness, dyspnea, and syncope (Kumar, 2023). 

  • b. If a provider prescribes medication to manage and treat chronic Afib, such as metoprolol, the patient should take it on time daily as instructed (Hazard Vallerand & Sanoski, 2019). They should not skip doses or double doses. 

  • c. Since Afib causes the atria to quiver, blood can stagnate in the atria, leading to an increased risk of clot formation (Banasik & Copstead, 2018). Therefore, patients should take anticoagulants at home, such as warfarin, apixaban, or rivaroxaban. 

  • d. Patients should follow up and seek a referral from a cardiologist to help monitor their chronic AFib. 

  • e. Patients should manage and mitigate general cardiovascular risk factors that can lead to AFib, such as hypertension, diabetes, obstructive sleep apnea, heart failure, and obesity (Kumar, 2023). 

  • f. If patients experience severe symptoms or have any concerns or indications that they may be in AFib, they should seek medical attention and/or go to the ED. 

The Intention of the Question: 

This question is written based on a patient I’ve taken care of in the past. Many of the patients I’ve taken care of have a history of Afib with minimal symptoms, and I’ve learned a standard routine and formula required to treat them. This question is aimed at encouraging the reader to identify the rhythm, think about immediate forms of treatment, and provide patient education as well, touching on multiple forms of knowledge application. 

References

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

Hazard Vallerand, A., & Sanoski, C. A. (2019). Davis’s drug guide for nurses (16th ed.). F.A. Davis Company. 

Kumar, K. (2023). Atrial fibrillation: Overview and management of new-onset atrial fibrillation. UpToDate. Retrieved April 24, 2025, from https://www-uptodate-com.offcampus.lib.washington.edu/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation?search=treatment%20for%20a-fib&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#H1 

Model Answer:

1. What does EKG show?

The EKG shows ST-segment elevation, which indicates acute injury to the heart muscle, suggesting a ST-Elevation Myocardial Infarction (STEMI)

2. What Labs would you recommend? List 3.

• 1) Troponin I or T

• 2) CK-MB (Creatine Kinase-MB) 

• 3) Complete Blood Count (CBC) or Basic Metabolic Panel (BMP) 

3. Based on the case scenario and EKG, what diagnosis would you suspect? Write a short summary to describe this diagnosis.

Acute ST-Elevation Myocardial Infarction (STEMI)

STEMI is a serious type of heart attack that occurs when a coronary artery becomes completely blocked, cutting off oxygen to part of the heart muscle and causing tissue damage or death. It is identified by a persistent ST-segment elevation on an ECG along with increased levels of cardiac biomarkers. Immediate treatment is critical to restore blood flow and minimize heart damage (Katikaneni et. al., 2025 & Reeder & Kenned, 2025). 

4. What of management should be initiated during acute phase?  List at least 2 medication and 2 treatments

• 1) Acute Pharmacrmacotherapy (Byrne et al., 2023)

  • I. Oxygen- Oxygen supplementation is recommended in ACS patients with hypoxemia (oxygen saturations <90%)

  • II. Nitrates- Sublingual nitrate may be helpful to relieve ischemic symptoms

  • III. Pain relief- intravenous opioids (e.g. morphine 5–10 mg) should be considered for the relief of severe chest pain.

  • IV. Intravenous beta-blockers- i.v. beta-blockers (preferably metoprolol) should be considered at the time of presentation in patients with a working diagnosis of STEMI undergoing PPCI with no signs of acute HF, a systolic blood pressure (SBP) >120 mmHg, and without other contraindications.

  • 2) Percutaneous coronary intervention (PCI): Primary PCI remains the preferred treatment method for patients with STEMI. Patients with PCI have high rates of thrombolysis in myocardial infarction, lower rates of intracranial outcomes, shorter hospital stays, and overall lower rates of major adverse cardiovascular events. In general, it is recommended to perform PCI in patients with STEMI within 12 hours of symptom onset (Partow-Navid et al., 2021).

  • 3) Emergency coronary artery bypass grafting (CABG) surgery should be considered for patients with a patent infarct-related artery (Byrne et al., 2023).

The Intention of the Question: 

When I worked in the ED in Taiwan, the hospital I worked at is a teaching medical center with a very busy workload. At that time, seeing at least 300 patients a day was considered normal, and the number could exceed a thousand during major holidays, such as Lunar New Year, when most clinics were closed. As a triage nurse then, sometimes I had only a couple minutes with patients who had unclear complaints to identify the severity of their condition and provide the necessary treatment. I remember a 75-year-old patient who came to the ED with his son on a cold night, reporting a toothache, sweating, slight shortness of breath, and chest discomfort. I immediately treated him as a potential MI case, but it turned out he only had a dental issue causing the discomfort. However, better safe than sorry.

MI is common diagnosis, especially in cold seasons, ST-segment elevation myocardial infarction (STEMI) is a critical and life-threatening condition that demands immediate, complex, highly coordinated care. Each year, there are approximately 605,000 new cases and 200,000 repeat cases of MI, resulting in an estimated $12 billion in hospital-related costs (Partow-Navid et. al., 2021).

References

Bhat, A. G., Verghese, D., Harsha Patlolla, S., Truesdell, A. G., Batchelor, W. B., Henry, T. D., Cubeddu, R. J., Budoff, M., Bui, Q., Matthew Belford, P., X Zhao, D., & Vallabhajosyula, S. (2023). In-Hospital cardiac arrest complicating ST-elevation myocardial infarction: temporal trends and outcomes based on management strategy. Resuscitation, 186, 109747–109747. https://doi.org/10.1016/j.resuscitation.2023.109747 

Byrne, R. A., Rossello, X., Coughlan, J. J., Barbato, E., Berry, C., Chieffo, A., Claeys, M. J., Dan, G.-A., Dweck, M. R., Galbraith, M., Gilard, M., Hinterbuchner, L., Jankowska, E. A., Jüni, P., Kimura, T., Kunadian, V., Leosdottir, M., Lorusso, R., Pedretti, R. F. E., … Ibanez, B. (2023). 2023 ESC Guidelines for the management of acute coronary syndromes. European Heart Journal, 44(38), 3720–3826. https://doi.org/10.1093/eurheartj/ehad191 

Katikaneni, P., Abbott, J. D., Qaseem, A., & Oettgen P. (2025, March 3). ST-elevation myocardial infarction (STEMI). DynaMedex. Retrieved April 26, 2025. from https://www.dynamedex.com/condition/st-elevation- myocardial-infarction-stemi-1 

Partow-Navid, R., Prasitlumkum, N., Mukherjee, A., Varadarajan, P., & Pai, R. G. (2021). Management of ST elevation myocardial infarction (STEMI) in different settings. The International Journal of Angiology, 30(1), 067–075. https://doi.org/10.1055/s-0041-1723944 

Reeder, J. S. & Kenned, H.L. (2025). Overview of the acute management of ST-elevation myocardial infarction. UpToDate. Retrieved April 19, 2025, from https://www.uptodate.com/contents/overview-of-the-acute-management-of-st-elevation-myocardial-infarction?search=MI&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#

Question #13 by Ana Frota Penha

A 74-year-old male patient is being monitored after atrial pacemaker implantation. One-week post-procedure, he presents to the emergency department with increasing shortness of breath and fatigue. During the assessment, the nurse notes tachycardia, hypotension, jugular venous distention, and muffled heart sounds upon auscultation. An echocardiogram reveals fluid accumulation around the heart.

Question: Based on the patient’s presentation and findings of muffled heart sounds and fluid around the heart, what is the most likely cause of these symptoms?

• A) Acute myocardial infarction leading to heart failure

• B) Cardiac tamponade due to post-operative hemorrhage

• C) Pulmonary embolism causing right-sided heart strain 

• D) Heart failure exacerbation due to fluid overload

Question #14 by Suman Roy

A 74-year-old male is admitted on your floor with shortness of breath and chest pain which is ongoing for several days and limiting his ability to go up the stairs to his bedroom. He has been sleeping in a recliner chair in his living room since then. He saw his doctor couple of day ago who made changes to his diuretics. He increased his torsemide from 10 mg to 30 mg bid. patient has seen no improvement with the new dosage. Now his symptoms are getting worse. His new symptoms are chest pain, dizziness, shortness of breath, wheezing, activity intolerance, palpitations, pain and numbness in his BLE. Vital Signs are BP 100/90, HR 110, R 26, O2 86 on RA and oral temp 97.8f. History: CHF, COPD, DMII, recurrent UTIs, pulmonary hypertension , depression and Hypothyroidism. Based on the information: 

What is happening with this patient? 

What do you anticipate the doctor to order to manage his condition? 

What lab values and imaging are expected for this patient. ( just basic lab values whether they will be elevated or decreased). 

Model Answer:

patient is experiencing acute on chronic CHF with hypoxia.  Being short of breath, activity intolerance , wheezing , chest pain and hypoxia suggesting a mix of pulmonary congestion, reduced cardiac output and possibly an COPD exacerbation. He is hemodynamic instable which is likely from inadequate perfusion. electrolyte imbalances secondary to torsemide can cause hypokalemia, hyponatremia and dehydration exacerbating symptoms like dizziness, weakness and palpitations. Potential for DVT given the symptoms of BLE pain and numbness. 

So anticipated doctor's orders: Chest X-ray to assess for pulmonary edema, effusion or pneumonia. Echo to evaluate heart function and assesses for worsening systolic or diastolic dysfunction or valves issues. BLE Doppler ultrasound to assess for DVT. Lab work: B-type Natriuretic Peptide( BNP) to assess the degree of heart failure. CBC to check for infection or anemia, CMP for electrolyte imbalances, renal function and liver function. Troponins to rule out MI or infarction. D-dimer to assess for PE .  Oxygen therapy as well to keep the O2 between 88% to 92% on RA. Medication: IV diuretics, Vasodilators, Bronchodilators, anticoagulation, continue cardiac monitor for arrhythmias, strict I&Os and daily weights.  

The Intention of the Question: 

Heart failure is the leading cause of admission in the United States. As a nursing student, they need to understand what the sign and symptoms of HF, diagnosis’s test and labs are needed. We see more patient getting admitted with this condition even though they come for a different health problem. 

References

Joseph, J. , Choudhury, A. & Kane, S.  (2022).  Acute Decompensated Heart Failure. Orthopaedic Nursing,  41 (4),  289-292. 

Mebazaa, A. (2015). Acute heart failure and cardiogenic shock: a multidisciplinary practical guidance. Intensive Care Medicine., 42(2), 147–163.

Model Answer:

1. What is the patient’s most likely diagnosis? Please support your answer with the patient’s clinical presentation.

The patient’s most likely diagnosis is classic/complete Kawasaki Disease. The patient presented with fever lasting for 5 days and 4 of the 5 principal features which are:

• a. bilateral bulbar conjunctivitis without discharge (Criteria #1: Bilateral injection of the bulbar conjunctivae with limbic sparing and without exudate);

• b. strawberry tongue (Criteria #2: erythematous mouth and pharynx, strawberry tongue and/or red, cracked lips);

• c. a diffuse, red rash on the child’s back (Criteria #3: polymorphous, generalized, erythematous rash, often with accentuation in the groin, which can be morbilliform, maculopapular, scarlatiniform, or erythema multiforme-like);

• d. swollen hands (Criteria #4: changes in the peripheral extremities consisting of erythema of the palms and soles and firm, sometimes painful, induration of the hands and feet)

The 5th principal feature absent in this child is acute, nonsuppurative, usually unilateral, anterior cervical lymphadenopathy with at least 1 node ≥1.5 cm in diameter. 

This is according to the diagnostic criteria established by Tomisaku Kawasaki in 1967 (Son, 2024) and is included in the American Academy of Pediatrics (AAP) Committee on Infectious Diseases report on diagnosis of Kawasaki Disease (Committee on Infectious Diseases, AAP, 2024).

2. What medication(s), considered as the treatment of choice, would you expect to be included in the treatment plan of this patient? What education might you provide for the patient’s family related to this/these medication(s)? Please list at least two examples of educational points to share with the patient’s parents/family.

Primary treatment of Kawasaki Disease consists of intravenous immune globulin. This is a single dose of IGIV 2g/kg, administered over 10 to 12 hours which results in rapid resolution of fever and other clinical and laboratory indicators of acute inflammation in approximately 85% of patients and has been proven to reduce the risk of coronary artery aneurysms from 17% to 4%. The treatment of choice is IGIV plus aspirin and should be started as soon as diagnosis is established or strongly suspected, whether or not coronary artery abnormalities are detected. Aspirin is used for its anti-inflammatory and antithrombotic activity. Aspirin alone does not decrease the risk of coronary artery abnormalities. High-dose aspirin (30-100 mg/kg per day) therapy is given until the patient has been afebrile for 48 to 72 hours. This is followed by low-dose aspirin (3 to 5 mg/kg/day, in a single dose) until a follow-up echocardiogram 2 to 8 weeks after onset of illness or is given indefinitely in patients whom coronary artery abnormalities are present (Committee on Infectious Diseases, AAP, 2024).

Nursing Education:

• Educate the family about possible IGIV infusion reactions such as chills and hypotension.

• Educate the family about the need for patients to be monitored daily for fever for a week after IGIV infusion. In cases of persistent fever, the diagnosis of Kawasaki disease should be reevaluated, but if Kawasaki Disease is still considered to be highly likely, the treatment should be intensified.

• Educate the family about the need to defer measles- and varicella-containing vaccines until 11 months after receipt of IGIV because of possible interference with development of an adequate immune response.

• Educate the family to avoid live attenuated varicella-containing vaccines during high-dose aspirin therapy because of a theoretical concern of Reye syndrome. Parents should be instructed to contact their child’s physician promptly if the child develops symptoms of or is exposed to influenza or varicella.

• Educate the family that the child and all household contacts older than 6 months should receive influenza vaccine according to seasonal recommendations. Non-live influenza vaccine should be used in the child receiving aspirin and family members can receive the non-live or live attenuated influenza vaccine. 

• Educate the family that ibuprofen should be avoided in children with coronary aneurysms taking aspirin (ibuprofen and other nonsteroidal anti-inflammatory drugs interfere with the antiplatelet effect of aspirin to prevent thrombosis)

The Intention of the Question: 

I rarely work with pediatric patients, and I wanted to learn more about a disease that I have not encountered. Making these quiz questions and coming up with a model answer allowed me to read about the diagnosis, pathophysiology, and treatment of patients diagnosed with this condition.

References

Son, M. B. F. (2024). Kawasaki disease: Clinical features and diagnosis. UptoDate. Retrieved April 28, 2025, from https://www-uptodate-com.offcampus.lib.washington.edu/contents/kawasaki-disease-clinical-features-and-diagnosis?search=kawasaki%20disease&source=search_result&selectedTitle=1%7E124&usage_type=default&display_rank=1 

Committee on Infectious Diseases, American Academy of Pediatrics. (2024). Kawasaki disease. In D. W. Kimberlin, R. Banerjee, E. Barnett, R. Lynfield, & M. H. Sawyer (Eds.), Red book: 2024-2027 report of the Committee on Infectious Diseases (33rd ed.). American Academy of Pediatrics.  https://doi-org.offcampus.lib.washington.edu/10.1542/9781610027373-S3_010_001 

Question #16 by Muskan Priya

You are working at Starbucks on a cold, snowy day. You are assigned to the drive-thru position, where you are constantly opening the window, talking to customers, and handling orders. As the shift progresses, you notice your fingertips are becoming increasing cold and uncomfortable. You asked to switch with your coworker, but she refuses to switch with you. She explains that she is unable to go into the drive thru position because when her fingertips start getting cold they turn white in color, then she struggles pressing the touchscreen buttons, which interferes with the order process. She mentions that she has a medical condition affecting her fingers but chooses not to disclose its name.

Since you are nursing school, you are curious about what condition might cause these symptoms and decide to investigate further.

Reflecting on this situation, answer the following questions: 

• Based on the coworker’s description of her symptoms, what condition might she have? 

• In your own words, create a brief description of this syndrome that would help you remember its key features?

• Is this condition classified as a primary or secondary form of the syndrome? What evidence helped you determine this? 

Model Answer:

Based on the coworker’s description of her symptoms, she might have Raynaud’s syndrome because she said that when her hands are in the cold, they start turning white and she is unable to press the buttons on the touchscreen. Since, her fingers are cold and turning white it is affecting her circulation in her fingertips. 

Raynaud’s is a syndrome or disease where there is decreased blood flow to the fingers. The blood vessels constrict in response to cold or stress, which causes limited blow flow, leading the affected areas to turn different colors. There are two different phenomena with this: the first one is most common in young and healthy individuals, especially in women with no underlying cause and the second is an underlying connective tissue disease. With primary Raynaud, the skin can turn white (pallor) to blue (cyanosis) and finally red (reperfusion) as circulation returns. 

This condition is classified as a primary form, since the coworker is a woman, other conditions weren’t listed and because her fingertips turned white, which happens in primary Raynaud phenomenon. In the secondary Raynaud, ulcers can happen, and skin looks smooth, shiny, and tight from loss of tissue, which she doesn’t have.

The Intention of the Question: 

I worked at Starbucks all through nursing school and so people always thought I knew their condition when they would describe it. But my coworker had this condition, and she was an MA, so she explained her condition and how it affected her, because of her I was able to remember about Raynaud’s.

References

Johns Hopkins Medicine. (2025). Raynaud's phenomenon. https://www.hopkinsmedicine.org/health/conditions-and-diseases/raynauds-phenomenon 

Model Answer:

This patient has concerning neurological symptoms, is hypertensive, and with neck pain, face pain and headache is displaying signs of a possible cervical or carotid artery dissection (Blum & Yaghi, 2015). A carotid artery dissection is when blood enters and flows through the separated layers of the carotid artery wall. She needs a focused neurological assessment including cranial nerves and a FAST exam. I would also gently auscultate her carotid artery with the bell of the stethoscope, listening for a bruit, or evidence of a local obstruction (Ball et al., 2023, Chapter 16). She needs stat imaging to look at the vessels in her neck and brain, so I would anticipate CT angiography neck/brain, and possible MRI/MRA (Goodfriend et al., 2022)

She is at risk of a stroke if the dissected artery causes embolization or reduces blow flow to cause thrombosis of intracranial vessels (Goodfriend et al., 2022).

The Intention of the Question: 

Carotid artery dissection is an emergency with severe potential complications including stroke. If the patient presents to your care before they have experienced stroke, emergent imaging is indicated for diagnosis for close neurological monitoring and stroke prevention measures including anticoagulation.

References

Ball, J., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier.

Blum, C. A., & Yaghi, S. (2015). Cervical Artery Dissection: A Review of the Epidemiology, Pathophysiology, Treatment, and Outcome. Archives of Neuroscience, 2(4), e26670. https://doi.org/10.5812/archneurosci.26670 

Goodfriend, S.D., Tadi, P., & Koury, R. (2022, December 21). Carotid Artery Dissection. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK430835 

Model Answer:

• 1) The contributing factors that may have led Ron to develop a DVT are his recent abdominal surgery requiring bedrest for the last 3 days and his metastatic colon cancer. Recent surgery requiring bedrest can lead to venous stasis, which can increase the risk of clot formation. Ron’s metastatic cancer diagnosis is also a contributing factor, as cancer can cause increased blood clotting. In addition to this, Ron’s history of smoking places him at an increased risk for a DVT (Waheed et al., 2023).

• 2) For cancer patients, LMWH/low molecular weight heparin (like enoxaparin, etc.)  is the preferred anticoagulation option for managing thrombosis. Thrombolysis treatment would not be the preferred treatment for this patient, as he has recently had abdominal surgery (Waheed et al., 2023).

• 3) If this DVT went unnoticed or was left untreated, Ron could develop a Pulmonary Embolism.  If the thrombus in his right leg broke free, it could travel to the lungs and cause a PE. Ron could also experience post-thrombotic (or postphlebitic) syndrome, where the veins in his foot or leg could experience pain, swelling, skin discoloration, and ulcers. Ron could also develop treatments from the administration of LMWH, like bleeding or hemorrhages (Mayo Clinic, 2022). 

The Intention of the Question: 

The intention of this question was to help the student think more about this patient’s diagnosis and what contributing factors may have led to this diagnosis, as well as thinking about the initial pharmacological treatment for this diagnosis and the seriousness of this diagnosis with the potential complications if left undiagnosed. The student should feel more comfortable in knowing the expected treatment plan when identifying a potential DVT in the future. 

References

Mayo Foundation for Medical Education and Research. (2022, June 11). Deep vein thrombosis (DVT). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/deep-vein-thrombosis/symptoms-causes/syc-20352557 

Waheed, S. M., Kudaravalli, P., & Hotwagner, D. (2025). Deep vein thrombosis. StatPearls. http://www.ncbi.nlm.nih.gov/books/NBK507708/ 

Question #19 by Teighler Gella

Ronald is a 60-year-old male that presents with intermittent cramping right calf pain. He states that it occurs when he’s walking for long periods of time but usually gets better when he stops and rests. He has a history of hypertension, hyperlipidemia, diabetes, CAD, and is a current smoker. He states that he’s prescribed medication for his blood pressure and cholesterol but only remember to take them once or twice a week. Ronald has had both of his elevated for about 10 minutes and upon assessment, you notice that his right leg is slight cooler and paler than the left leg.

• 1. Given Ronald’s history and symptoms, what do you suspect his causing his RLE pain? Why?

• 2. What focused physical assessment(s) would you do to support your suspicion? Name and describe at least one.

• 3. If your suspicion is correct, what education would you provide Ronald? Name at least two.

Model Answer:

• 1. Ronald’s history of hypertension, hyperlipidemia, diabetes, and cardiovascular disease combined with his symptoms of calf pain that relieves after rest is likely early peripheral artery disease, specifically stage 2. It is caused by lack of blood flow to the musculature which results in pain to the muscle groups. Early PAD can present like Ronald where pain occurs when the muscle group is being used. It may progress to constant pain especially when the extremity is elevated. Ulcers may form from a wound that fails to heal from insufficient blood flow. 

• 2. Physical assessments can include:

  • a. Assessing pulses – specifically femoral, popliteal, dorsalis pedis, and posterior tibialis arteries. You can palpate and auscultate pulses and compare strength from different points and opposite extremities.

  • b. Bedside ABI – recording blood pressure in the arm and leg to get a ratio. ABI < 0.9 is considered abnormal

• 3. Education can include:

  • a. Smoking cession

  • b. Management hypertension and cholesterol

  • c. Contact provider if:

    • i. Pain is persistent

    • ii. Further dhanges in sensation, color, size of extremity

    • iii. Non-healing wound or ulcer

The Intention of the Question: 

Although this case is not based on a personal story, my intension is to highlight how important it is to identify early signs of PAD. Early identification could prevent complications like limb amputation and sepsis from wounds. 

References

DynaMedex. Peripheral Artery Disease (PAD) of Lower Extremities. EBSCO Information Services. Accessed April 28, 2025. https://www-dynamedex-com.offcampus.lib.washington.edu/condition/peripheral-artery-disease-pad-of-lower-extremities 

Neschis, D., & Golden, M. (2024, September 9). Lower extremity peripheral artery disease: Clinical features and diagnosis. UpToDate. https://www-uptodate-com.offcampus.lib.washington.edu/contents/lower-extremity-peripheral-artery-disease-clinical-features-and-diagnosis?search=peripheral%20artery%20disease&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#H380415680 

Model Answer:

1. Robert's two key abnormal physical findings that suggest a complication beyond simple airflow obstruction are the presence of jugular venous distention (JVD) and bilateral pitting edema with hepatomegaly. Instead of a single worsening of airflow limitation from COPD, these findings are suggestive of systemic venous congestion, which suggests right-sided heart failure. Without noticeable symptoms of volume overload, people with mild COPD progression usually have increased respiratory symptoms such as coughing, wheezing, and dyspnea (DynaMedex, 2025). In Robert's case, the combination of peripheral edema, hepatic congestion, and high jugular vein pressure points to a cardiac problem, most likely cor pulmonale or right-sided heart failure brought on by chronic lung illness (North & Schmidt, 2025). 

2. It is important to differentiate whether Robert’s symptoms are primarily from COPD progression or another cardiac cause because the underlying etiology significantly influences treatment decisions. Management of COPD focuses on improving bronchodilation, addressing hypoxia, and promoting smoking cessation. Whereas the presence of right heart failure would also require volume management with the use of diuretics and therapies targeting pulmonary hypertension (North & Schmidt, 2025). If Robert’s symptoms were due to left-sided heart failure, cardiac therapies such as ACE inhibitors, beta-blockers, and more aggressive diuresis would be necessary. Misdiagnosing the problem could lead to inappropriate or possibly harmful treatments.  For example, excessive diuresis could impair preload and worsen hypoxemia in COPD patients if not carefully managed. 

The Intention of the Question: 

The intention of the questions is to assess whether the learner can recognize when a patient with COPD is showing signs of a complication beyond simple airflow obstruction, specifically right-sided heart failure (cor pulmonale). The case requires the learner to apply clinical reasoning by interpreting physical findings like JVD, hepatomegaly, and peripheral edema, and to differentiate between COPD progression and cardiac causes. It also challenges the learner to understand how this distinction directly affects management decisions, since the treatment for heart failure differs significantly from the management of COPD alone. 

References

DynaMedex. (2025). COPD. Retrieved April 28, 2025, https://www-dynamedex-com.offcampus.lib.washington.edu/condition/copd#GUID-39FEBFEE-0578-4262-91F8-3137B3314854 

North, I., & Schmidt, G. A., (2025). Management of the patient with COPD and heart disease. UpToDate. Retrieved April 28, 2025, https://www.uptodate.com/contents/management-of-the-patient-with-copd-and-heart-disease