Harding: Critical Thinking Cases in Nursing, 7th Edition (2024)

1. Is this couple infertile? Defend your response.

Yes, infertility is defined as the inability to conceive after 1 year of regular, unprotected intercourse.

2. What type of infertility does the couple have, primary or secondary?

Primary. Primary infertility exists with couples who have never conceived. Secondary infertility exists when couples who have conceived previously are now unable to do so.

3. What are the common causes of male infertility?

Most men have sperm abnormalities. There may be a low sperm count, slow motility, abnormally shaped sperm, or small ejacul*tory volume. The body can produce antibodies against sperm, or there may be structural abnormalities causing occlusions. Hormonal imbalances, impaired erections, impaired ejacul*tory ability, genetic conditions, drug and alcohol use, smoking, exposure to toxins, and some medications may impair fertility.

4. What are the common causes of female infertility?

Ovulatory disorders are the most common cause of female infertility. These include problems with hormonal imbalances (estrogen, progesterone, and FSH levels) and structural abnormalities such scarring from STIs or endometriosis, abnormalities in the shape and size of the uterus, the presence of uterine fibroid tumors, and blockages in the fallopian tubes. Increased age, drug and alcohol use, smoking, being over or under weight, and excessive exercise may impair fertility.

5. Describe the reproductive and sexual history you need to obtain from the couple.

6. In addition to performing a general physical examination, what laboratory tests do you expect the provider to order?

Chart View

General Assessment

7. J.B. needs a sem*n analysis. What instructions will you give him about specimen collection? Select all that apply.

1. Keep the container in an insulated bag with ice.
2. Bring the specimen to the office within 8 hours.
3. Place the specimen in a clean container for transport.
4. He can collect the specimen in a sterile, nonlubricated condom.
5. He should not have sex or ejacul*te for 2 to 5 days before the procedure.

8. What information is obtained from a sem*n analysis?

9. The provider orders thyroid stimulating hormone (TSH), follicle stimulating hormone (FSH), estradiol, and progesterone levels for L.B.; a luteinizing hormone (LH) level for J.B.; and TSH levels for both. When will you schedule these tests?

10. What is the purpose of BBT charting?

BBT is measured at home using a special thermometer that specifically measures temperature between 96° F and 100° F (35.6°C and 37.8°C). The process helps predict the most fertile days in the menstrual cycle when ovulation occurs. BBT decreases just before ovulation and rises at ovulation, staying elevated for up to 3 days. If the cycle is charted for 3 to 4 months, a pattern can be recognized, and sex can be timed accordingly.

11. What teaching will you provide L.B. on how to perform BBT charting?

Have L.B. use an oral thermometer that is accurate to at least 0.1 degrees. Have her take her temperature orally immediately after waking each morning. She should keep the thermometer at her bedside, so she can take it without getting out of bed and prior to doing anything else. Record the temperature on a paper chart or an app. Note if any special circ*mstances (e.g., illness, late waking) exist that may affect her temperature and have her note them.

12. Outline the teaching you will provide L.B. on how to use an ovulation kit.

Ovulation tests work by detecting LH. Just before ovulation, women experience an LH surge, or a sudden, brief increase in LH. Women are at their peak fertility 36 hours after the LH surge. Ovulation tests detect the surge by measuring LH in urine. A positive test result means a woman is most likely fertile over the next 3 days. Because L.B.’s cycle is as short as 28 days, she should start testing on day 12. To perform the test, she will either urinate on the stick or dip the stick in a cup of urine. If the stick color changes, the LH surge is present. She should perform the test at the same time each day.

13. Because lifestyle and sexual practices can affect fertility, what do you encourage the couple to do to enhance their ability to conceive? Select all that apply.

1. Relax in a hot tub daily before going to bed.
2. Avoid the use of artificial lubricants during sex.
3. Have them drink alcohol before sex to help relax.
4. Eat a healthy diet with plenty of fruits and vegetables.
5. Use strategies that are usually helpful in reducing stress.
6. Engage in moderate exercise for 30 minutes, 3 to 4 times per week.

14. As you are finishing the appointment, L.B. begins to cry and says, “I can’t believe this is happening to us when all of my friends are just popping out babies.” How do you respond?

Provide therapeutic, nonjudgmental listening, and allow L.B. to freely express her concerns. Explain feelings of anger, helplessness, or sadness over difficulties conceiving are natural responses. Describe how many women never imagine experiencing a problem having a child and when it happens, it is a shock. Allow time for her to express her anger and talk about her feelings. It may be helpful to say, “It is okay to be angry” or “It must be hard to believe all this is going on.” Encourage the couple to be open with each other for mutual support. Offer counseling to help L.B. individually and L.B. and J.B. as a couple to help them cope with what they are experiencing.

Chart View

Laboratory Results

15. How will you describe a HSG to the couple?

A HSG looks at the uterus, fallopian tubes, and ovaries. A special dye is injected into the uterus, followed by x-ray to determine whether the uterine cavity is normal and if the fluid spills out of the fallopian tubes. Blockage or other problems often can be found.

16. You tell L.B. that it is important for her to call the office when her menstrual cycle starts so the HSG can be scheduled between days 7 and 10 of her cycle. It is important they abstain from sex between the first day of her cycle until after the test. L.B. asks why. What do you tell her?

Because an HSG could flush a potential fertilized ovum out through a uterine tube into the peritoneal cavity, the procedure is scheduled in this manner so there is no possibility of pregnancy at the time of the test.

17. What is the expected outcome associated with each of these medications?

Clomiphene stimulates the pituitary gland to increase secretion of LH and FSH. This results in ovarian stimulation, promoting follicular maturation and ovulation. Prescribed progesterone supplements corpus luteum production of natural progesterone, which is needed to support the uterine lining and a pregnancy should one occur.

18. You determine that L.B. understands your teaching about clomiphene therapy when she says: (Select all that apply.)

1. “I do not need to use the LH testing kits anymore.”
2. “There is a higher risk of my having twins, or more.”
3. “I will take this medicine orally for 5 days each month.”
4. “I may experience some flushing and breast tenderness.”
5. “My husband will need to learn to give me daily injections.”

1. What is the best response to J.H.’s concern?

1. “Let’s talk more about your concern and what is going on.”
2. “Have you discussed with your wife how important sex is to her?”
3. “Don’t worry, we can start you on medications that will help you have sex again.”
4. “That sounds normal. Couples tend to have sex less often the longer they are married.”

2. Describe the history you need to obtain from J.H.

Perform a complete review of systems and current medications, including nonprescription drugs, vitamin and herb use, and drug and alcohol use. In the sexual history, evaluate the onset of ED (gradual or abrupt); whether there is difficulty achieving or maintaining an erection; the adequacy of erection; any changes in libido and the timing of such; quality and timing of org*sm; volume and appearance of ejacul*te; presence of any sexually induced genital pain; and the presence and quality of nocturnal erections. Determine whether the onset is related to a specific event.

3. What are the primary risk factors for ED?

Organic risk factors include diabetes, prostatectomy, hypertension, smoking, alcohol use, endocrine disorders, drug side effects, multiple sclerosis, spinal cord trauma, low testosterone levels, COPD, obesity, pelvic radiation, coronary artery disease, peripheral vascular disease, and hyperlipidemia. Functional risk factors include stress, depression, and anxiety.

4. What should be included in J.H.’s physical assessment?

BP and heart rate; body type and BMI for obesity; cardiovascular, neurologic, and genitourinary systems, including penile, testicular, and prostate exams (performed by the provider)

5. What laboratory tests do you expect the provider will order and why?

A serum glucose and lipid profile will rule out diabetes mellitus. Testosterone and thyroid hormone levels will show any endocrine-related problems. Blood chemistries and a complete blood count may help identify systemic diseases.

6. What other diagnostic tests may be done to evaluate ED?

Vascular studies can help identify if a vascular problem is interfering with erection. Penile Doppler ultrasound assesses penile blood inflow, blood trapping, and outflow in response to injection of a vasoactive drug. Penile angiography can evaluate the penile vascular blood supply and locate any vascular damage. Nocturnal penile tumescence and rigidity testing assesses the presence and integrity of nocturnal erections. These are useful in differentiating between organic or psychological causes of ED.

7. While waiting on the results of laboratory work, the provider decides to start J.H. on sildenafil (Viagra) 50 mg orally once daily as needed, 30 minutes to 1 hour before sexual activity. How does sildenafil work?

Sildenafil is a phosphodiesterase enzyme 5 (PDE5) inhibitor. It enhances smooth muscle relaxation and the inflow of blood into the corpus cavernosum, while reducing venous outflow. Together, this causes engorgement and allows an erection to occur. Sexual stimulation is required.

8. You review J.H.’s medical record to verify that it is safe for him to take sildenafil. What may preclude J.H. from taking sildenafil?

Sildenafil is used cautiously in those with coronary artery disease, active peptic ulcer disease, bleeding disorders, retinitis pigmentosa, sickle cell disease, any anatomical obstruction that would predispose to priapism, and taking nitrates or beta blockers.

9. You teach J.H. about which common side effects of sildenafil? Select all that apply.

1. Flushing
2. Headache
3. Dizziness
4. Sleepiness
5. Constipation
6. Hypertension

Correct answers are: a, b, c, d

10. What teaching will you provide J.H. about the safe use of sildenafil?

Refrain from using alcohol or being in a hot tub if he takes sildenafil. During sex, if he becomes dizzy or nauseated or has pain, numbness, or tingling in his chest, arms, neck, or jaw, stop and call emergency medical care. Stop using sildenafil and call the provider at once if he has sudden vision or hearing loss; swelling in the feet, ankles, or hands; or shortness of breath. Seek medical care if his erection is painful or lasts 4 hours or longer.

11. After teaching J.H. about the safe use of sildenafil, you determine your teaching has been effective if he says:

1. “I should contact my provider if I have any vision loss.”
2. “We can have sex all night because my erections will last 3 to 4 hours.”
3. “Having a few beers before will help the medication work more quickly.”
4. “I can take two in 1 day on special occasions if I don’t have any chest pain.”

12. Describe 4 other treatments options for ED.

13. Describe the counseling you will provide to J.H. to help him cope with the psychosocial implications of ED.

Discuss with J.H. his expectations for sexual functioning and encourage him to verbalize any fears and anxiety about sexuality and body image changes. Help him work through any self-defeating, negative thoughts. Discuss ways to promote open communication with his wife so they can talk openly about their sexual needs. Describe alternative sexual expressions, including hugging, kissing, massage, and physical intimacy. Review strategies to manage stress.

Chart View

Laboratory Test Results (Fasting)

14. Which, if any, of J.H.’s laboratory results concern you and why?

Though his total cholesterol is below 200 mg/dL (5.2 mmol/L), his HDL should be above 45 mg/dL (1.2 mmol/L) and the LDL should be less than 130 mg/dL (3.4 mmol/L). Triglycerides should be less than 160 mg/dL (1.8 mmol/L) for men. His glucose level is consistent with prediabetes and needs to be monitored.

15. The provider adds metformin 500 mg orally twice daily to J.H.’s medication regimen. Why?

Physiologic factors cause most ED. Obesity, dyslipidemia, and high glucose levels suggest J.H. has metabolic syndrome. Treating this potential cause of ED may help in restoring his sexual function.

16. A teaching plan for J.H. should include which intervention? Give your rationale.

1. Removing all sugars from his diet
2. Exploring lower stress career options
3. Following a liquid meal replacement diet
4. Exercising 60 minutes, 4 to 5 times per week

17. How will you handle J.H.’s request?

Although the U.S. Food and Drug Administration calls pill splitting risky and does not encourage it unless a drug’s package insert specifically says it is approved for splitting, many providers and health plans follow the practice. J.H. could verify with his pharmacy what he would save and if he still wishes, convey the request to the provider.

18. What will you tell J.H. is the safest way to split a pill?

J.H. should use a pill splitter because this will come closest to dividing the pill into precise halves. They are inexpensive and widely available. He should never use a knife, scissors, razor blade, or any other sharp tool because they can create unequal parts. Remind him to replace a splitter when it no longer divides pills easily and accurately.

1. What factors influence the choice of the most appropriate method of birth control?

The woman’s overall health, age, frequency of sexual activity, number of sexual partners, desire to have children in the future, and history of certain diseases

2. What past medical information will you need to obtain from P.B. and why?

3. What lifestyle information will help you aid P.B. in choosing a birth control method?

Does she think she can remember to take a pill at the same time every day—that is, does she have a consistent schedule? Does she think she would remember to change a patch on a weekly basis? Does she think she would remember to change a ring monthly? Would she be able to go to her provider’s office for an injection on a regular basis? If a method interrupts lovemaking, would she still be motivated to use it?

4. P.B. asks you about the effectiveness rating of available birth control methods. Describe the term efficacy.

Efficacy is how effective the method is at preventing pregnancy during “typical use.”

5. What factors influence how effective a contraceptive method is?

Frequency of intercourse, motivation to prevent pregnancy, understanding of how to use the method, adherence to method, provision of short- or long-term protection, consistent use of the method

6. Match the available contraceptive methods according to their efficacy ratings:

Correct answers are: 1C, 2A, 3C, 4B, 5A, 6A, 7C, 8B, 9C, 10B

7. P.B. asks you to review the main advantages and disadvantages of the hormonal birth control methods first.

8. After reviewing the hormonal methods, you choose to discuss intrauterine devices. How would you describe the copper and levonorgestrel (Mirena) IUD systems to P.B.?

IUDs are inserted into the uterus to provide continuous pregnancy prevention. Both are shaped like the letter T. A copper IUD is effective for 10 years and women might notice heavier periods with more cramping. Mirena works by thickening the cervical mucus to prevent sperm from entering the upper reproductive tract. Side effects include initial irregular bleeding. A benefit of this method is that after 4 months, menstrual bleeding and cramping are dramatically reduced. Mirena is effective for 5 years. Fertility returns promptly when either device is removed. IUDs are expensive at the time of insertion but have a low long-term cost. Most are inserted at the provider’s office.

9. Next, you steer the conversation to barrier methods. What will you share with P.B. about the use of a diaphragm or cervical cap and condoms?

These nonhormonal methods do not have the systemic effects that hormonal methods have. They leave all reproductive function intact and are used only in conjunction with the act of intercourse. Condoms (male and female) are available without a prescription and offer some protection against STIs. They are widely available. However, many couples find they interfere with the sensations of intercourse. The diaphragm and cervical cap provide hormone-free contraception and must be professionally fitted and prescribed by a health care provider. They do need to be used in proximity to intercourse and are more likely than other methods to be used incorrectly. Both need to be used with a spermicide. Spermicides (e.g., foam, creams, jellies) kill sperm in the vagin*.

10. The major advantage of using a condom for birth control is that condoms:

1. Do not require monthly injections
2. Are easy to obtain and inexpensive
3. Reduce the risk for acquiring infections
4. Come in assorted styles, shapes, and textures

11. Describe what you would tell P.B. about the natural family planning method.

Natural family planning requires women to observe their cycles for physiologic evidence of ovulation such as changes in body temperature, cervical mucus, or position during and after intercourse. Some women use a method of contraception during their fertile time; others choose to abstain during that time. Natural family planning avoids the use of drugs, chemicals, and devices. Both partners need to be invested in this method of contraception.

12. P.B. wants to know about the associated costs with each method because she is on a tight budget. How would you respond?

Most insurance plans cover prescription contraceptives and procedures without having a copayment or cost applied to the deductible. Methods available over the counter are not covered by insurance. Natural family planning and withdrawal are free.

13. She asks you which method you would pick. What do you tell her?

This is her decision, so an important issue is that she find the right fit for her lifestyle, medical profile, and preferences. Ask her questions such as, “What attributes in a contraceptive are most important to you?” “What side effects could you tolerate, and which would you not want?” and “What role does your partner want to play in preventing pregnancy?” These open-ended questions might help her clarify her choices.

14. Explain how biphasic OC pills work.

Biphasic pills vary the amount of estrogen, progestin, or both over the active pill days to try to mimic the normal menstrual cycle and minimize side effects.

15. When should P.B. take her first OC?

OCs can be started one of 3 ways. 1. Same-day start: She starts that day. A backup method of birth control is recommended during the first week of use. 2. First-day start: She can start within 24 hours of the onset of her menses. 3. Sunday start: She starts on the first Sunday after the menses begins. Backup contraception for 7 days is necessary if menses did not begin on a Sunday. The advantages of a traditional Sunday start are avoiding periods on the weekend and convenience, in that many manufacturers label the first pill in a pack as a “Sunday” pill.

16. You tell P.B. that is does not matter what time of day she takes the OC, just that she takes it at the same time each day. Describe 3 suggestions you can offer to help her remember to take her pill.

17. What should you tell her about missed pills?

Missed pills, especially at the beginning or the end of the pack, might allow ovulation and unintended pregnancy to occur. If she misses the first tablet of a new cycle, take the missed tablet as soon as she remembers and take the next tablet at the usual time. She may take 2 tablets in 1 day, then continue the regular dosing schedule. She should use another birth control method until she has taken 7 days of tablets after the missed dose. If she misses 1 tablet during the cycle, take the missed tablet as soon as she remembers. Take the next tablet at the usual time. She may take 2 tablets in 1 day, then continue the regular dosing schedule. If she misses 2 tablets in a row in the first or second week, take 2 tablets on the day that she remembers and 2 tablets the next day, then continue taking 1 tablet a day. Use another birth control method until she begins a new cycle. If she misses 2 tablets in a row in the third week or 3 or more tablets in a row at any time during the cycle, either throw out the current pack and begin a new pack or keep taking 1 tablet a day from the current pack until Sunday. Then, on Sunday, throw out the old pack and begin a new pack. Use another birth control method until she has taken 7 days of tablets after the last missed dose. If she misses any of the last 7 (inactive) tablets, there is no danger of pregnancy.

18. How will you prepare P.B. for possible side effects?

Advise her that breakthrough bleeding is the most common adverse effect during the first few months, and it usually improves with each cycle. If bleeding persists despite correct use, tell her to come in for an examination to rule out infection or other problems. Tell her that scanty periods are common OCs. If nausea occurs, switch to the opposite time (morning to evening) or take with food.

19. Using the acronym ACHES, what symptoms should you teach P.B. to report?

20. Are there any other key points you should review?

21. A few months later, P.B. calls the clinic because she missed a dose of her first week of OC the prior day and cannot remember what you told her. What will you tell her? Select all that apply.

1. “Throw that pill away. Restart taking your pills tomorrow.”
2. “It’s okay; you’re still protected from pregnancy if you take two now.”
3. “You should use a backup form of contraception for the next 7 days.”
4. “Please make an appointment so we can insert a temporary intrauterine device.”
5. “Don’t take any more pills. Begin a new pack when you start your next menses.”
6. “Take the missed pill now, along with today’s pill, then resume the pack tomorrow.”

1. What key sexual and health history questions do you need to ask R.Z.?

2. What should be included in R.Z.’s physical assessment?

Perform a general inspection of all skin, noting lesions, rashes, or discoloration. Inspect the mouth, noting any lesions. Palpate axillary, cervical, sublingual, and inguinal lymph nodes. Inspect pubic hair for infestations and lesions. Palpate scrotal contents, noting any masses, tenderness, or swelling. Examine the penile skin and glans for ulcers, warts, lesions, rashes, and signs of inflammation. Inspect the meatus for lesions, redness, and drainage. Examine perianal areas for lesions, rashes, discharge, warts, and fissures.

3. R.Z.’s physical examination is unremarkable except for the genital examination. The urethral meatus is red with a mucopurulent discharge. Given his symptoms and findings, what differential diagnoses do you consider?

4. What diagnostic tests do you expect the provider to order and why?

Chart View

Laboratory Test Results

5. Based on the assessment and diagnostic test results, what problem does R.Z. have?

R.Z. appears to have contracted gonorrhea.

6. What are your overall goals of nursing care for R.Z.?

Understand the risks associated with STIs, complete treatment and return for appropriate follow-up for the STI, assist in notifying sexual contacts about testing and treatment, and understand safer sex practices

7. How is this problem treated?

The CDC recommends combination therapy with ceftriaxone 250 mg as a single IM dose and azithromycin 1 gram orally in a single dose.

8. The provider orders ceftriaxone 250 mg IM. How many milliliters will you give for this dose? Mark the syringe with your answer. Round to the tenth.

(From Gray Morris D. (2010). Calculate with confidence (5th ed.). 5, St. Louis, MO: Mosby.)

Correct answer: 0.7 mL (250 mg/x:350 mg/1 mL)

(From Gray Morris D. (2010). Calculate with confidence (5th ed.). 5, St. Louis, MO: Mosby.)

9. Where is the best place to inject the ceftriaxone?

Ventrogluteal site, because ceftriaxone should be injected into a large muscle group

10. What teaching will you provide R.Z. to promote successful treatment?

Taking medications as prescribed is a key component of patient teaching. Tell R.Z. to avoid all sexual contact while he is being treated, for 7 days after treatment, and until all sexual partners have completed a full course of treatment and are asymptomatic, so the medicine will have time to work. Advise him to return if symptoms persist or recur and to return in 3 months for re-testing to be sure he has avoided reinfection. Stress that having a cured infection does not protect him from becoming reinfected and discuss condom use.

11. What complications may R.Z. develop if treatment is not successful?

In men, untreated gonorrhea can cause epididymitis or orchitis, which may result in infertility. It can affect the prostate by causing scarring inside the urethra, making urination difficult. If gonorrhea spreads to the blood or joints, it can cause a life-threatening infection.

12. R.Z. says he is not going to tell his wife, because “she is going to kill me,” or his work associate, because he is embarrassed. What are the possible complications in women if this STI remains untreated?

Women with initial asymptomatic gonorrhea may develop pelvic inflammatory disease, chronic pelvic pain, and Bartholin abscesses. They have a higher risk for ectopic pregnancy and infertility. The presence of gonorrhea in the lower genital area can increase the risk for contracting and transmitting HIV. A few may develop disseminated gonococcal infection.

13. What symptoms do women with this STI commonly experience?

Increased vagin*l discharge, dysuria, frequency of urination, or bleeding after sex. Redness and swelling can occur at the cervix or urethra along with a purulent exudate.

14. R.Z. asks if you are going to tell anyone about his infection. How do you respond?

Gonorrhea is a reportable STI in all U.S. states and territories. Laws mandate providers, laboratories, or both report gonorrhea cases to the local public health authorities.

15. What implications might this diagnosis have for R.Z. and his wife?

Given that R.Z. is in a committed relationship, the diagnosis of an STI implicates one of the partners had sexual activity with a person outside of the marital relationship. This knowledge may be met with a variety of emotions such as shame, anger, and a desire for vengeance. R.Z. and his wife will need support and counseling. A referral for professional counseling to explore the ramifications of an STI in their relationship may be indicated.

16. What advice do you offer R.Z. about telling both women?

Tell R.Z. he is obligated to tell both women in a truthful, honest manner, about the infection so they may receive the appropriate treatment. Acknowledge that the conversation with his wife will not be easy. Have him plan to have the conversation in a comfortable place. He can begin by telling his wife he has something upsetting to tell her, then relate that he saw the provider, was diagnosed with gonorrhea, and is undergoing treatment. Be honest about the events preceding the diagnosis. Relate that she will need treatment. He can follow a similar approach with his co-worker, telling her he recently saw a provider, was diagnosed with gonorrhea, and she needs to see a provider for treatment.

17. R.Z. pauses for a moment, then asks if it is possible for someone from the health department to tell his work associate. How do you respond?

R.Z. will be asked to supply the health department with the names of his sexual partners from the past 60 days. This is called partner notification. The process allows health workers to notify them of possible exposure to an STI, and help them access testing, treatment, and counseling. The partner-notification process is confidential and follows HIPAA regulations. R.Z.’s name will not be revealed to the work associate.

18. Which additional instructions will you include in your discharge teaching?

1. “Make sure you do not have sexual intercourse for 21 days.”
2. “It is important to wash your hands frequently so you don’t spread the infection.”
3. “You will need to come back for a follow-up appointment if the drainage does not stop.”
4. “If you do have sexual intercourse in the next 7 days, have your partner douche afterward.”

19. R.Z. asks what he could do to prevent getting another infection. You determine he understands your teaching when he states:

1. “I will not have sex with women I do not know.”
2. “Using a spermicidal cream will decrease my risk.”
3. “I will use a fresh condom each time I have intercourse.”
4. “If I don’t see any signs of infection, then that partner is safe.”

1. Identify 3 conditions that would require emergency care and could prove life-threatening.

Uncontrolled hemorrhage because of early pregnancy loss, excess endometrial tissue, fibroid tissue, ectopic pregnancy with a ruptured fallopian tube, miscarriage, pelvic inflammatory disease, cancerous lesion in the uterus

2. She asks you, “Could I be pregnant?” How will you respond?

Yes. Explain that women in their forties may have an unplanned pregnancy because they think they are too old to conceive and their irregular cycles mean they are no longer fertile. Because she still is having cycles, although irregular, she is likely still able to conceive; and because she went 2 months without a period, there is a possibility she is pregnant. You explain that if she is pregnant, there is a higher incidence of miscarriage because the eggs are older and sometimes do not develop properly, and the level of hormone in the luteal phase might be too low to sustain a pregnancy.

3. You ask her how she would feel if she was pregnant, and she says, “It would ruin my life.” She states she is a single mother with 2 children in high school. What can you tell her to help her with her obvious distress?

“Let’s complete your examination so we can find out the cause of the bleeding. Many women have these feelings, especially at this time in their lives. If you are pregnant, there is plenty of time for you to think about what choices are best for you. You have a lot of options open to you.”

4. Describe the assessment needed to determine what might be occurring with S.K.

5. What is your priority concern as you care for S.K.?

The increased bleeding may have caused fluid volume deficit and anemia.

Chart View

Laboratory Test Results

Vital Signs

6. Interpret S.K.’s laboratory results and vital signs.

All her values are within normal limits. She is not pregnant, nor does she have the same presentation as someone hemorrhaging with imminent hypovolemic shock.

7. S.K. is obviously relieved about not being pregnant, but she expresses fear the bleeding could be caused by cancer. What will you tell her to reassure her?

In a woman her age, the most likely cause of abnormal bleeding is changes in hormone levels associated with menopause.

Chart View

Physician’s Orders

Infuse 1 L of D₅ LR over 4 hours

Meperidine 5 mg IV now

8. Before administering the meperidine, what will you ask her?

Ask her whether she has ever had a reaction to this or similar drugs or if she is taking any antidepressants, especially monoamine oxidase inhibitors (MAOIs).

9. What precautions do you need to take to safely administer meperidine? Select all that apply.

1. Administer the medication undiluted
2. Have oxygen equipment and naloxone at her bedside
3. Administer the dose over a minimum of 4 to 5 minutes
4. Place her in semi-Fowler position with her head to the side
5. Monitor S.K.’s respiratory status every 15 minutes for 1 hour after

10. You are preparing to infuse the D₅ LR. The available IV tubing supplies 15 gtt/mL. At how many drops per minute will you regulate the infusion?

11. What is your immediate concern and why?

S.K. is experiencing respiratory depression related to receiving IV meperidine. Without immediate treatment, she could experience respiratory arrest.

12. What actions will you initiate?

You need to begin resuscitation efforts by calling for assistance, applying oxygen, and supporting her respirations with a resuscitation bag as needed. Prepare and administer IV naloxone. Support her respirations and frequently monitor her status until the naloxone takes effect. You will need to remain with S.K. until her status is stabilized. Notify the provider of what has happened.

13. What is the most likely cause of S.K.’s bleeding and why?

Her abnormal bleeding is likely related to hormonal changes associated with perimenopause. Increased bleeding is correlated with a change from ovulatory to anovulatory cycles and is associated with unopposed high estrogen levels the week before menses. Estrogen causes endometrial tissue to thicken, leading to heavier periods.

14. S.K. asks if there is any way to stop the bleeding. How will you respond?

The usual treatment for heavy, irregular bleeding in midlife is low dose oral contraceptive pills. A combination of estrogen at 20 to 25 mcg with a progestin should stabilize the uterine lining. The pills will control her current bleeding and regulate her future cycles, which should protect against anemia from any excess blood loss each month.

15. What risk factors will you ask her about because she is starting oral contraceptives?

16. What warning signs and symptoms do you need to teach her as she starts oral contraceptives?

Because of the higher dose initially, she should be warned to call if she has any “aches.” She should immediately report any acute pain in her head, chest, or extremities. Warn her about the possibility of nausea with the extra estrogen boost. She might want to take an over-the-counter antiemetic 30 minutes before taking the dose or take it with food.

17. Which statements indicate S.K. understands the discharge instructions? Select all that apply.

1. “I can take 325 mg of aspirin every 6 hours for the cramping pain.”
2. “I will try to eat more beans and spinach over the next several days.”
3. “I will call if I continue to have heavy bleeding, soaking a pad an hour.”
4. “I will avoid sexual intercourse until the bleeding has completely stopped.”
5. “If I get dizzy or feel my heart beating funny, I will come back to the emergency room.”

1. Which assessment findings are significant and why?

Elevated temperature and heart rate, pelvic pain, and purulent vagin*l discharge are all associated with chlamydial infection.

2. What medical interventions can you expect?

Administering pain medication, treating the infection with antibiotics, rehydrating A.P. with oral fluids to offset fluid loss from her elevated temperature

3. What are the risk factors for chlamydia?

Having multiple sex partners; not using or using a condom incorrectly

4. Describe the common symptoms of chlamydia infection in men and women.

Men may have pain with urination or a urethral discharge. They rarely have pain or swelling of the testicl*s. Symptoms in women include mucopurulent discharge, bleeding, dysuria, and painful intercourse. Symptoms of rectal chlamydial infection can include rectal pain, discharge, and bleeding.

5. What are the consequences of an untreated chlamydia infection in women?

Sterility, increased risk for ectopic pregnancies, pelvic inflammatory disease, reactive arthritis, and dermatologic problems

6. How will you offer emotional support to A.P.?

A.P. might express guilt, apprehension, and fear of rejection. Establish and maintain open communication; encourage A.P. to ask questions; give straightforward, easily understood answers to all questions. Provide an atmosphere in which she feels comfortable expressing her feelings and asking questions. Be warm and supportive; encourage her to express her feelings. Use concerned listening if she expresses negative feelings.

7. Which choice is best for A.P.? Explain your reasoning.

Azithromycin. Because the one-time dose is the full course of treatment, it eliminates concern with adherence with the medication regimen part of treatment.

8. You tell A.P. that chlamydial infection is a sexually transmitted infection (STI) that must be reported to the health department. What is the purpose of reporting the infection, and what actions will the health department take?

The purpose of notifying the health department is to enable measures to be taken to control the transmission of the infection. A caseworker from the health department will contact her and ask her to name sexual contacts. The caseworker then tries to find all the contacts as soon as possible; caseworkers often find the contacts even if supplied with only limited information. Those contacts are told they have been exposed to an STI and are encouraged to seek medical evaluation. The caseworkers, who are often nurses, are aware of the social implications of these diseases and the need for discretion. Sexual contacts are often not informed about the origin of the information naming them as a contact so that cooperation and privacy are ensured.

9. A.P. says she does not understand why her partners must be told about the infection. How will you respond?

Many men with chlamydial infections have no symptoms. Because the infection can have serious health effects, including infertility, reporting is important so that those infected receive treatment to reduce their risk for serious health effects and stop the spread of the infection to others. Stress that the persons contacted by the health department will not be informed of her identity.

10. Based on the information A.P. has given you, you decide that she is at risk for other STIs and unplanned pregnancy. Based on the “5 Ps,” what risk assessment questions do you need to ask A.P.?

11. You ask whether someone has talked with A.P. about “safe sex.” She laughs. Undaunted, you ask if she would be willing for you to discuss the use of condoms with her sexual partners. She tells you that she is already careful; if she does not “know the guy,” then she uses a condom. How are you going to respond?

Tell her you understand she tries to be careful, but you are concerned about her. You cannot tell by looking at someone whether he or she has an STI or HIV. Using a condom will help in preventing an STI and unplanned pregnancy.

12. You ask A.P. whether she has been tested for HIV. She says no, she does not know anyone with acquired immunodeficiency syndrome (AIDS) and she only has sex with “100% straight guys.” Now what are you going to say?

Tell her HIV happens with “straight guys.” One of the fastest growing groups acquiring HIV is women with multiple sex partners. Heterosexual men may have an infection from another infected woman or through another practice, such as using injected drugs.

13. You ask her whether she would like to be tested for HIV. You tell her the test will not cost her anything, only she will know the results, no one else, and test results are completely confidential. She agrees to the test. What counseling will you provide A.P.?

Offer information about the HIV test, a review of safe sex practices, information about the confidentiality of test results, and receiving the results. You will need to have her make an appointment for her to receive test results and posttest counseling.

14. You make an appointment for A.P. to return to the clinic in 1 week for her HIV test results. Describe the instructions you will give to A.P. before she leaves the clinic.

Review the use of the prescribed antibiotic and the importance of completing the course of therapy. She should not engage in further sexual activity for 7 days. If she is not able to do that, stress she must use a condom until a cure is established. She should rest and limit her activities until her fever and symptoms have resolved. For pain, she can take over-the-counter analgesics as recommended and apply heat to the lower abdomen and back. If perineal pads are needed for collection of vagin*l discharge, change them often. She should often cleanse the perineal area with mild soap and water, followed by rinsing and patting dry. Note the character, amount, color, and odor of vagin*l discharge. Teach her the symptoms of complications and the need to report problems promptly.

15. What are your primary nursing concerns right now?

Evaluating her for compliance with treatment for the chlamydial infection, assessing her for complications, and counseling her about sexual practices so she can avoid acquiring another STI

16. A.P. has completed the course of antibiotic therapy and is not experiencing any symptoms. After counseling her on ways to reduce her risk for acquiring another STI, you determine A.P. understood your teaching about safe sexual practices if she says she will: (Select all that apply.)

1. Have her partner wear a new condom with each sexual encounter
2. Not worry about contacting an STI if the man says he has few partners
3. Apply a new application of spermicidal jelly before each sexual encounter
4. Douche with an over-the-counter solution within 4 hours of having intercourse
5. Inspect the genitalia of her partner before intercourse or other contact with perianal area

1. What concerns you most right now about T.C. and why?

With the shallow respirations, respiratory rate of 16, Spo₂ of 93%, and temperature of 99.7° F (37.6oC), T.C. appears to be experiencing postoperative hypoventilation. If not reversed, it could lead to development of atelectasis and pneumonia.

2. Identify 3 factors likely affecting T.C.’s respiratory status.

Most anesthetic agents and adjuvant medications given intraoperatively affect both rate and depth of respiration. IV opioids used for pain control affect the respiratory system, especially in the immediate postoperative period. Lying in the same position for extended periods can lead to stagnation of pulmonary fluids during surgery and induce a degree of atelectasis. Incisional pain can affect the depth of respirations.

3. Name 5 interventions you need to implement to promote T.C.’s respiratory status.

4. Formulate a plan for the UAP and you to care for T.C. during your shift.

After you perform a complete assessment, work out a schedule with the UAP so that one of you will monitor VS, level of consciousness, and Spo₂ every 15 minutes until T.C. is more awake. Give specific parameters to the UAP for which you need to be notified. Instruct the UAP that you want T.C. to continue oxygen therapy. You will be the one performing subsequent assessments and teaching T.C. about coughing, deep breathing, and incentive spirometer use; the UAP can then remind T.C. to perform these activities hourly. The UAP can help T.C. with changing positions at least every 2 hours.

5. Which of T.C.’s vital sign values would be most important for the UAP to report to you at once?

1. Heart rate of 100 beats/min
2. Temperature of 100° F (37.8° C)
3. Respiratory rate of 9 breaths/min
4. Blood pressure of 160/80 mm Hg

6. Name 3 outcomes you expect for T.C. because of your interventions.

Answer will vary. VS and pulse oximetry within normal limits, an increase in depth of respirations, clear lung sounds or T.C. is able to show effective coughing, deep breathing, and use of incentive spirometry.

7. Discuss how PCA devices are used for controlling pain.

PCA is used to give low doses of analgesic at frequent intervals to deliver a more continuous level of pain control. A loading dose is delivered initially to raise the blood level to an effective range. The patient then self-administers to keep the blood level within an effective range, based on his or her perception of the pain. The medication, amount delivered with each dose and time interval between doses might need to be adjusted to achieve the greatest effectiveness.

8. During the first 24 hours, T.C. has 122 PCA demands and 31 doses delivered. How many total milligrams of morphine sulfate did she receive?

62 mg (31 × 2 mg)

9. What adjustments could be made to her plan of care to better control her pain?

T.C. might need an adjustment in her dose and lock-out interval on the PCA, with a shorter lock-out interval. Reinforce teaching about the use of the PCA. Giving another analgesic might prove effective if used in conjunction with PCA.

10. What other measures can you use to manage T.C.’s pain more effectively?

You could have T.C. use nonpharmacologic therapies, such as focused breathing and relaxation, distraction, imagery, positioning, and the use of heat or cold compresses. These all have the advantage of not causing respiratory depression.

11. How do you best evaluate the effectiveness of the PCA therapy?

1. Assess the time interval between doses received
2. Have T.C. state her pain level on a scale of 1 to 10
3. Determine how many doses of morphine T.C. received
4. Appraise whether T.C. understands the purpose of PCA therapy

12. What 2 assessments do you need to make and why?

Assess the wound: An increase in bloody drainage could be a sign of a hemorrhage, wound infection, dehiscence, or disruption in clotting function. Obtain VS to assess for signs of hemorrhage.

13. How should her wound appear at this time?

There may be some scabbing on the incision and slight swelling around the staples and wound edges. The incision may appear erythematous and feel slightly warm to the touch. There should be a small to moderate amount of bloody drainage.

14. When you remove the dressing, you note a large amount of bloody drainage coming from the distal end of the wound. What other assessments do you need to obtain?

Assess her perineal pad for bleeding and clots; auscultate heart, lung, and bowel sounds; assess urine output; and inspect color and temperature of her skin

15. Her assessment findings are unremarkable, and you place a new sterile dressing on the wound. What will you do next?

Even though her assessment does not reveal any other signs of complications, you still need to report the bleeding promptly to the surgeon and continue to monitor T.C. for any further bleeding. Document the appearance of the wound, your assessment findings, and that you notified the surgeon of what is occurring.

16. What do you do and why?

You sit down to share with them that you are willing to listen. Threats of legal action are based on many issues. Anger and disappointment are among the most common. Many legal conflicts are preventable and stem from two parties not communicating or understanding each other or from a difference between expectations and actual outcomes, so promoting communication is a key role at this point. Your role is to offer the best opportunity for the patient and provider to work through their differences.

17. You state, “Tell me what’s going on with you right now. Maybe I can help you be more comfortable.” What would be the benefit of taking this approach?

In situations like this, people usually are emotionally “loaded.” They think providers have not listened to or acknowledged them. They might just need to vent their frustrations. You are acknowledging they have legitimate needs and are providing them with a chance to verbalize their feelings and work through what is happening. Consider a referral to a risk manager who is skilled at helping both parties work through potential problems. Tell them you are going to call the surgeon and relate that they are upset; then place the call. Remember, from their perspective, T.C. came in for a hysterectomy, has had two surgeries, and is worse than when she started. Ask them whether there is anything you can do for them right now to make them more comfortable. Addressing physical needs facilitates deescalation of crises.

18. What referrals might be beneficial?

Consider a referral to a risk manager, social worker, or patient ombudsman who is skilled at helping both parties work through potential problems. Tell them you are going to call the surgeon and relate that they are upset; then place the call.