case study; The evolving patient-Elvis presley, Exams of Nursing

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case study; The evolving patient-Elvis presley Case Study: The Evolving Patient - Elvis Presley Question 1 of 7 A 75-year-old male, Elvis Presley, is brought to the emergency department by his son. The son reports that his father, who has a history of hypertension, has been experiencing "the worst headaches of his life" for the past two weeks. This morning, the client had an episode of tonic-clonic shaking lasting approximately 60 seconds, followed by a period of confusion. The son also notes, "He just hasn't been himself lately, he's much more irritable." The nurse completes the initial assessment. Which of the following findings is most concerning and requires immediate communication with the provider?

Exhibit: Nursing Notes

August 26, 2025, 09:15 Client brought to ED by son. Son reports client has had worsening headaches over the last 2 weeks, rating them "10/10." States client had a "seizure" this morning at home, describing tonic-clonic movements for about 1 minute, with post-event confusion. Son also reports personality changes, stating the client is more irritable than usual. Client is currently alert and oriented to person and place, but not to time. Complains of a generalized headache rated 8/10 and appears drowsy.

Exhibit: History & Physical

August 26, 2025, 09:30 Patient Name: Elvis Presley Age: 75 Gender: Male Past Medical History: Hypertension (HTN), Hyperlipidemia Past Surgical History: Cholecystectomy (2010) Social History: Retired musician. Smoked 1 pack per day for 40 years, quit 15 years ago. Occasional alcohol use. Presenting Complaint: Worsening headaches, new-onset seizure activity, personality changes.

Exhibit: Flow Sheet

August 26, 2025, 09:20 Blood Pressure: 172/94 mm Hg Heart Rate: 54 bpm Respiratory Rate: 14 breaths/min Temperature: 98.6°F (37.0°C) SpO2: 96% on room air Pain: 8/10, generalized headache

A. The blood pressure of 172/94 mm Hg. B. The client’s complaint of a headache rated 8/10. C. The family's report of recent personality changes. D. The report of new-onset tonic-clonic seizure activity.
case study; The evolving patient-Elvis presley

Rationale

Correct Answer: D. The report of new-onset tonic-clonic seizure activity in an older adult is the most concerning finding. Seizures can be a presenting sign of a primary brain tumor or metastasis and indicate significant cerebral irritation. This represents a critical neurologic change that requires immediate investigation to identify the underlying cause and prevent recurrence. Incorrect Answers: e A.While the blood pressure is elevated, it could be a result of pain, anxiety, or a compensatory response to increased intracranial pressure (Cushing's triad includes bradycardia, hypertension with a widening pulse pressure, and irregular respirations). The seizure is a more specific and alarming sign of a primary neurological event. e B.Asevere headache is a common symptom of a brain tumor due to increased ICP, but a seizure represents a more acute and dangerous manifestation of neurologic dysfunction. e C. Personality changes are a significant symptom associated with intracranial tumors, particularly those in the frontal lobe, but they develop over time. The new-onset seizure is an acute event that poses a greater immediate risk to the client's safety.

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Question 2 of 7 The provider has admitted the client to the neurological unit for further evaluation. A non-contrast CT scan of the head was performed in the ED, and an IV has been established. The client is now reporting nausea and has vomited once. He also states the lights in the room seem "too bright." The nurse reviews the admission orders and diagnostic results. Based on the available data, the nurse should recognize that which of the following findings are consistent with increased intracranial pressure (ICP)? (Select all that apply.)

Exhibit: Nursing Notes

August 26, 2025, 11:30 Client admitted to the neuro unit. Rates headache as 9/10. He is increasingly drowsy but arousable to verbal stimuli. Complaining of nausea; vomited 150 mL of clear fluid. Client requests lights to be dimmed, stating they are "bothering my eyes." Family is at the bedside and is very anxious.

Exhibit: Provider Orders

August 26, 2025, 11:00 e Admit to Neurological Unit. e NPO except for sips of water with medications. case study; The evolving patient-Elvis presley Question 3 of 7 The nurse is performing a scheduled neurological assessment. The client is more difficult to arouse than he was two hours prior. When aroused, he knows his name but is now unsure where he is and mumbles his responses. His right pupil is 4 mm and sluggish to react, while the left is 3 mm and brisk. His vital signs are updated on the flow sheet. Which hypothesis is the priority for the nurse to consider at this time?

Exhibit: Nursing Notes

August 26, 2025, 13:30 Client noted to be sleeping. More difficult to arouse than on previous assessment. Arouses to a loud voice and sternal rub. Is oriented to person only. Speech is mumbled. Right pupil is 4 mm and sluggishly reactive to light; left pupil is 3 mm and briskly reactive. Left-sided weakness noted, with arm drift.

Exhibit: Flow Sheet

August 26, 2025, 13:25 Blood Pressure: 185/88 mm Hg Heart Rate: 50 bpm Respiratory Rate: 10 breaths/min, irregular pattern Temperature: 99.0°F (37.2°C) SpO2: 93% on room air Pain: Unable to assess reliably, client moans to stimulus.

A. The client is oversedated from the levetiracetam. B. The client is progressing toward cerebral herniation. C. The client is experiencing an acute ischemic stroke. D. The client is developing a hospital-acquired infection.

Rationale

Correct Answer: B. The constellation of findings—declining level of consciousness, anisocoria (unequal pupils) with a sluggish reaction, new focal motor weakness (left arm drift), and worsening Cushing's triad (increasing hypertension, worsening bradycardia, irregular respirations)—are classic signs of uncal herniation. This is a life-threatening emergency where the brain tissue is being shifted due to extremely high ICP, compressing the brainstem. This is the most urgent and life-threatening hypothesis. Incorrect Answers: e A. While levetiracetam can cause drowsiness, it would not typically cause pupillary changes, focal deficits, or the severe vital sign changes seen here. These signs point to a structural problem, not a medication side effect. e C. While the client has focal deficits, the overall clinical picture, including the known large mass, midline shift, and progressive decline, is more consistent with brain case study; The evolving patient-Elvis presley herniation than a new ischemic stroke. The vital sign changes are classic for herniation, not stroke. e D. The client has a low-grade temperature, but there are no other signs of infection. The neurological decline is the most prominent feature and is better explained by the known brain mass and increasing ICP.

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Question 4 of 7 The provider was notified of the client's neurological decline. A stat MRI confirmed the tumor was a glioblastoma. The client was stabilized with mannitol and hypertonic saline, and a craniotomy for tumor debulking is scheduled for tomorrow morning. The nurse is developing the client's preoperative plan of care. Which outcomes should the nurse prioritize for inclusion in the plan of care? (Select all that apply.)

Exhibit: Nursing Notes

August 26, 2025, 14:00 Provider at bedside. New orders received. Client stabilized after administration of mannitol. LOC improved to drowsy but arousable and oriented to self and place. Neurosurgery consulted; client is scheduled for craniotomy for tumor debulking in the AM. Son at bedside, expresses understanding of the plan but appears overwhelmed.

Exhibit: Provider Orders

August 26, 2025, 13:45 STAT head CT. Mannitol 1 g/kg IV over 30 minutes, once. Prepare to transfer to Neuro-ICU. Notify neurosurgery immediately.

Exhibit: Lab/Diagnostic Results

August 26, 2025, 16:00 MRI Brain w/wo Contrast: Confirms large, irregular, peripherally enhancing mass in the right frontal lobe consistent with glioblastoma (astrocytoma Grade IV). Significant vasogenic edema with increased midline shift to 1.5 cm. No evidence of acute hemorrhage.

A. The client will remain free from injury. B. The client will demonstrate improved nutritional intake. C. The client and family will verbalize reduced anxiety. D. The client will participate in case study; The evolving patient-Elvis presley infusing as ordered. Client and son verbalize understanding of the upcoming surgery. Surgical consent signed and on the chart.

Exhibit: MAR

Scheduled Medications: Dexamethasone 4 mg IV every 6 hours (Last dose: 06:00) Levetiracetam 500 mg IV every 12 hours (Next dose: 09:00) 0.9% Sodium Chloride at 75 mL/hr PRN Medications: Ondansetron 4 mg IV every 6 hours PRN Acetaminophen 1000 mg IV every 6 hours PRN (Last dose: 04:00)

Exhibit: Flow Sheet

August 27, 2025, 06:00 Blood Pressure: 142/84 mm Hg Heart Rate: 72 bpm Respiratory Rate: 16 breaths/min Temperature: 98.4°F (36.9°C) SpO2: 98% on room air Pain: 2/10, headache Neuro: A&O x3, PERRLA, moves all extremities equally.

A. Administer the 09:00 dose of levetiracetam early. B. Verify that the surgical consent form is signed and witnessed. C. Complete a final, comprehensive neurological assessment. D. Remove the client's dentures and any jewelry. E. Ensure a patent IV is in place.

Rationale

Correct Answers: B, C, D, and E. Standard preoperative procedures are essential for patient safety. eB. Ensuring informed consent is a critical legal and ethical responsibility before any invasive procedure. e C.A final baseline neurological assessment is crucial for comparison with postoperative assessments to detect any changes. e D. Removing dentures and jewelry is a standard safety measure to prevent aspiration, obstruction, or injury during surgery and anesthesia. e E.A patent IV is necessary for the administration of anesthesia and emergency medications. Incorrect Answer: e A. Medications should be given as scheduled unless there is a specific order to do otherwise (e.g., "on-call to OR" medications). Administering the antiepileptic drug early without an order would be a medication error. The nurse should clarify with the provider or anesthesia if there are questions about the timing of the dose.

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case study; The evolving patient-Elvis presley Question 6 of 7 The client's surgery was successful for maximal tumor debulking. The surgeon utilized Gliolan (aminolevulinic acid hydrochloride) to help visualize the tumor margins during the procedure. The client is now in the neuro-ICU. The nurse reviews the postoperative orders. Which provider order requires the nurse to implement a priority environmental safety measure specific to the medication administered during surgery?

Exhibit: Nursing Notes

August 27, 2025, 14:00 Client returned from PACU to Neuro-ICU. Intubated and sedated. Dressing to head is clean, dry, and intact. Two peripheral IVs patent. Indwelling urinary catheter draining clear yellow urine. Family updated on arrival.

Exhibit: Provider Orders

August 27, 2025, 13:30 (Postoperative Orders) Admit to Neuro-ICU. Maintain head of bed at 30 degrees. Neurological assessments every 1 hour. Dexamethasone 4 mg IV every 6 hours. Levetiracetam 500 mg IV every 12 hours. Fentanyl infusion for sedation and analgesia. Strict 1&0. Maintain SBP < 160 mmHg. Maintain SpO2 > 94%.

A. Maintain head of bed at 30 degrees. B. Neurological assessments every 1 hour. C. Maintain SBP < 160 mmHg. D. The unwritten implication of using Gliolan.

Rationale

Correct Answer: D. Gliolan (aminolevulinic acid hydrochloride) is an agent that accumulates in tumor cells and fluoresces under blue light, helping the surgeon differentiate tumor from normal tissue. A critical side effect is significant photosensitivity. The nurse must protect the client's eyes and skin from strong light, including direct sunlight and bright indoor lights, for at least 24 hours after administration to prevent severe burns. This environmental precaution is a priority directly related to the intraoperative medication. While no order is explicitly written, clinical knowledge of the drug's side effects mandates this action. case study; The evolving patient-Elvis presley

Rationale

Correct Answers: B, D, and E. The family is expressing anticipatory grief and feeling overwhelmed. The nurse's role is to provide support and resources. B. Providing a safe space for the client and family to express their feelings is a therapeutic intervention that validates their emotions and builds trust. D. A palliative care consultation is appropriate for any patient with a serious, life-limiting illness, regardless of prognosis. Palliative care focuses on symptom management and quality of life and can be provided alongside curative treatment. For a diagnosis like glioblastoma, early referral to hospice or palliative services is beneficial. E. Referring the family to support groups can provide them with peer support and practical coping strategies from others with similar experiences. Incorrect Answers: A. This is dismissive and non-therapeutic. While online information can be overwhelming, telling the son to stop looking invalidates his attempt to understand the situation. A better approach would be to guide him to reputable sources. C. This offers false reassurance and discourages the family from planning for the future, which is a necessary part of coping with a terminal diagnosis. F. This is a form of false reassurance. While it may be true, it dismisses the family's current fears and does not address their immediate need for support and practical resources.

Case Study: The Evolving Patient - Michael Jordan Question 1 of 7 Michael Jordan, a 68-year-old retired athlete, presents to the neurology clinic for evaluation. He tells the nurse, "For the last few months, my right hand just shakes when I'm sitting watching TV. It stops if | pick up the remote. My wife says | don't smile anymore, and it feels like I'm walking through mud." After completing the initial assessment, which finding should the nurse recognize as a cardinal manifestation of Parkinson's Disease?

Exhibit: Nursing Notes

September 10, 2025, 10:00 Client presents for evaluation of new-onset tremor. Reports a right-hand tremor that case study; The evolving patient-Elvis presley occurs at rest and resolves with purposeful movement. He endorses a feeling of generalized slowness, especially when initiating movement. His wife, who is present, states the client's face appears "flat" and he has developed a slight stoop in his posture. Client denies any pain but expresses frustration with his symptoms.

Exhibit: History & Physical

September 10, 2025, 10:15 Patient Name: Michael Jordan Age: 68 Gender: Male Past Medical History: Osteoarthritis, hyperlipidemia Physical Examination: e General: Alert and oriented. Affect is flat. e Neurologic: Subtle, low-amplitude "pill-rolling" tremor noted in the right hand while client is seated with hands in lap; tremor subsides with action. Mild cogwheel rigidity noted in right arm upon passive range of motion. Gait is slow to initiate with a shortened stride. Posture is slightly stooped.

A. The client's flat affect. B. The client's stooped posture. C. The tremor that occurs at rest. D. The client's report of feeling slow.

Rationale

Correct Answer: C. A resting tremor, often described as "pill-rolling," is one of the four cardinal manifestations of Parkinson's Disease. It characteristically appears when the limb is at rest and decreases with voluntary movement, which is consistent with the client's presentation. Incorrect Answers: e A.A flat affect, or "masked facies," is a common clinical manifestation but is not considered one of the four cardinal signs (tremor, rigidity, bradykinesia, postural instability). e B.Astooped posture is a common finding related to postural instability, but the instability itself is the cardinal sign, not just the posture. e D. The subjective feeling of slowness is a symptom of bradykinesia, but the objective resting tremor is a more specific cardinal sign observed during the assessment.

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Question 2 of 7 case study; The evolving patient-Elvis presley e C. There is no cure for Parkinson's Disease. Pharmacologic treatment is directed at controlling symptoms and maintaining functional independence. e . While this statement is true and a positive goal, the question asks about the understanding of the medication teaching. This statement relates to general disease management, not the medication itself.

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Question 3 of 7 Six months later, Mr. Jordan is brought to the emergency department after a fall. His wife states, "He was trying to walk to the kitchen and just froze in place and fell over. It's been happening more lately." She also mentions he has been complaining of seeing "little bugs on the floor that aren't there." The ED nurse performs an assessment. For each finding below, click to specify if it is an expected manifestation of Disease Progression, a Medication Side Effect, or an Unrelated Finding. Each row must have only one selection.

Exhibit: Nursing Notes

March 15, 2026, 14:30 68-year-old male brought to ED via private vehicle after a fall at home without loss of consciousness. Client is alert and oriented x4. Reports pain in his left wrist. Wife reports client has had increasing difficulty with walking, describing episodes of "freezing." She also reports client has been experiencing visual hallucinations for the past month.

Exhibit: MAR

Home Medications: e Carbidopa-levodopa 25-100 mg PO TID e Atorvastatin 40 mg PO daily e Acetaminophen 650 mg PO PRN for joint pain

Exhibit: Flow Sheet

March 15, 2026, 14:45 BP (Lying): 138/84 mmHg, HR: 88 bpm BP (Standing): 110/72 mmHg, HR: 104 bpm Respiratory Rate: 18 breaths/min SpO2: 97% on room air Pain: 5/10 in left wrist

Finding Disease Medication Side Effect Unrelated Finding Progression Postural Instability oO Oo oO case study; The evolving patient-Elvis presley Orthostatic o o oO Hypotension Visual Hallucinations o o oO Export to Sheets

Rationale

| Finding | Disease Progression | Medication Side Effect | Unrelated Finding | | :--- | :---: | :---: | | Postural Instability | & | 0 | O|| Orthostatic Hypotension | 0 | % | 0 | | Visual Hallucinations |O | X | O| Postural Instability: Problems with standing, walking, and balance (postural instability) are a cardinal sign of Parkinson's Disease that typically worsens over time as the disease progresses. "Freezing" is a common manifestation of this. Orthostatic Hypotension: The significant drop in blood pressure and compensatory increase in heart rate upon standing is orthostatic hypotension. This is a common autonomic side effect of carbidopa-levodopa and other antiparkinsonian medications. Visual Hallucinations: Psychiatric changes, including hallucinations and psychosis, can occur in Parkinson's Disease but are also well-documented side effects of dopamine-agonist medications like levodopa, especially in later stages or at higher doses.

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Question 4 of 7 Mr. Jordan is admitted to the medical unit for observation and a physical therapy consult. The next morning, the nurse observes that he is experiencing significant rigidity and bradykinesia, making it very difficult for him to get out of bed and perform morning care. His next dose of carbidopa-levodopa is due in 30 minutes. What is the nurse's priority action?

Exhibit: Nursing Notes

March 16, 2026, 07:30 Client awake and alert. Reports feeling very "stiff" this morning. Significant rigidity noted in all extremities. Movements are very slow. Attempted to get out of bed to use the bedside commode but required assistance of two staff due to severe bradykinesia. Expresses frustration, stating "I can't get my body to move." Next dose of carbidopa-levodopa is scheduled for 08:00.

case study; The evolving patient-Elvis presley
Nursing Problem Consult Speech-Language Offer Preferred Provide Thickened Pathologist Foods Liquids Dysphagia Oo Oo oO Poor Oral Intake O o o Risk for o o o Aspiration Export to Sheets

Rationale

| Nursing Problem | Consult Speech-Language Pathologist | Offer Preferred Foods | Provide Thickened Liquids | | :--- | :---: | t---! | -—-! | | Dysphagia | & | 0 | | | Poor Oral Intake | 0 | & | 0 | | Risk for Aspiration | 0 | O|@] Dysphagia: Dysphagia (difficulty swallowing) is a serious complication of Parkinson's Disease. A formal swallowing evaluation by a Speech-Language Pathologist (SLP) is the priority intervention to diagnose the extent of the dysphagia and recommend the safest food and liquid consistencies. Poor Oral Intake: While poor intake is related to dysphagia, a simple and effective nursing intervention to encourage eating is to offer the client preferred foods and make mealtimes pleasant. This addresses the appetite component of the problem. Risk for Aspiration: The client's observed coughing with thin liquids indicates a high risk for aspiration. While an SLP consult is necessary, the immediate priority to ensure safety is to modify the liquid consistency. Providing thickened liquids is a direct intervention to reduce the risk of aspiration.

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Question 6 of 7 The client is now stable and preparing for discharge. The nurse provides extensive education to Mr. Jordan and his wife regarding home safety modifications to prevent future falls. Which of the following statements by the wife indicate a need for further teaching? (Select all that apply.) case study; The evolving patient-Elvis presley

Exhibit: Nursing Notes

March 18, 2026, 11:00 Provided discharge teaching to client and wife, focusing on fall prevention and home safety. Discussed medication schedule, signs of complications, and the importance of follow-up with PT and neurology. Wife verbalized understanding and a plan for home modifications.

A."| will remove all the throw rugs from the living room and hallways." B. "I should install a raised toilet seat and grab bars in the bathroom." C. "I'll make sure he wears soft, loose-fitting slippers around the house to be comfortable." D. "We can use a rolling walker, but | should probably take the wheels off to make it more stable." E. "I'll make sure the pathways in our home are well-lit, especially at night."

Rationale

Correct Answers: C and D. e C. Slippers, especially loose-fitting ones, do not provide adequate support and can increase the risk of tripping and falling. The client should wear proper, well-fitting shoes with non-skid soles. e D. Removing the wheels from a rolling walker makes it a standard walker, which may not be appropriate for a client with Parkinson's. A shuffling gait can be made worse by having to lift the walker with each step. A rolling walker is often recommended to promote a more fluid gait pattern. Any modification to an assistive device should be done in consultation with a physical therapist. Incorrect Answers: e A.Removing throw rugs is a key intervention to prevent trips and falls. This statement indicates correct understanding. eB. Installing bathroom safety devices like raised toilet seats and grab bars is an important adaptive measure to promote safety and independence. This statement indicates correct understanding. e E. Ensuring adequate lighting is essential to prevent falls, especially for clients with postural instability. This statement indicates correct understanding.

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Question 7 of 7 Two weeks after discharge, Mrs. Jordan calls the neurology clinic. She sounds distressed and states, "He's having a really bad day. He can barely move, and he says his medicine isn't working. We've been trying to get him to his physical therapy appointment all morning, but he's just too stiff to get in the car." His last dose of carbidopa-levodopa was four hours ago, and the next is due now. case study; The evolving patient-Elvis presley

Exhibit: Nursing Notes

October 30, 2025, 13:15 Client presents for evaluation of progressive weakness. Reports onset six months ago with left-hand clumsiness. Symptoms have now ascended to her left shoulder. She notes frequent, visible muscle twitches in her biceps and calves. She also reports two recent falls due to her "left leg giving out." Husband notes her speech has become noticeably slurred (dysarthria) in the past month. Client appears anxious but is articulate and insightful regarding her symptoms. She states, "| know my body, and something is very wrong."

Exhibit: History & Physical

October 30, 2025, 13:45 Patient Name: Serena Williams Age: 43 Gender: Female History: No significant past medical history. Physical Examination: Mental Status: Alert, oriented, with intact cognition. Mood is anxious. Speech: Moderate dysarthria noted. Motor: Marked atrophy and 3/5 weakness in the left hand and forearm. 4/5 weakness in the left lower extremity. Widespread fasciculations noted in all extremities. e Reflexes: 3+ deep tendon reflexes in all extremities with a positive Babinski sign on the left. e Sensation: Sensation to light touch and pinprick is intact throughout.

A. Asymmetric limb weakness B. Altered level of consciousness C. Fasciculations and muscle atrophy D. Hyperreflexia E. Numbness and tingling in the extremities

Rationale

Correct Answers: A, C, and D. ALS is a disease characterized by the progressive loss of both upper and lower motor neurons. e A. The disease often presents with asymmetric, progressive limb weakness, as seen in this client starting with her left hand. eC. Fasciculations (muscle twitching) and muscle atrophy are classic signs of lower motor neuron degeneration. e D. Hyperreflexia and a positive Babinski sign are signs of upper motor neuron damage, which is also a hallmark of ALS. The combination of upper and lower motor neuron signs is key to the diagnosis. Incorrect Answers: eB. Cognitive function and consciousness remain intact throughout the course of ALS, even in the final stages. This is a distinguishing feature of the disease. e EE. Sensation is not affected in ALS. The disease process is purely motor. case study; The evolving patient-Elvis presley

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Question 2 of 7 Ms. Williams is diagnosed with ALS. One year later, she is admitted to the hospital with a fever, productive cough, and shortness of breath. Her husband reports she has had significant difficulty swallowing for the past month and has been coughing after every meal. Based on the most recent assessment data, which potential complication is the most immediate threat to the client?

Exhibit: Nursing Notes

November 5, 2026, 09:30 Client admitted to the medical floor from the ED with aspiration pneumonia. She is awake, alert, and fully oriented. Appears frail and fatigued. Weakness is now profound in all extremities. Speech is very soft and difficult to understand. She is visibly dyspneic at rest, using accessory muscles to breathe. Her cough is weak and ineffective.

Exhibit: Lab/Diagnostic Results

November 5, 2026, 08:00 Chest X-Ray: Right lower lobe infiltrate, consistent with aspiration pneumonia.

Exhibit: Flow Sheet

November 5, 2026, 09:30 Blood Pressure: 142/88 mm Hg Heart Rate: 114 bpm Respiratory Rate: 28 breaths/min, shallow Temperature: 101.4°F (38.6°C) SpO2: 89% on 4L nasal cannula

A. Septic shock B. Acute respiratory failure C. Nutritional deficit D. Venous thromboembolism (VTE)

Rationale

Correct Answer: B. The client's clinical presentation—including dyspnea at rest, accessory muscle use, a weak cough, shallow respirations of 28/min, and an SpO2 of 89% on supplemental oxygen—strongly indicates impending acute respiratory failure. Progressive respiratory muscle weakness is the ultimate cause of death in most ALS patients, and this client's aspiration pneumonia has dangerously exacerbated her already compromised respiratory status. Incorrect Answers: