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HESI: Cystic Fibrosis Questions and Rationale Graded A+
- Which assessment supports the diag- nosis of CF? A fever of 102 ºF (38.9 ºC), inflamed larynx with exudate. Eyes with redness and yellow exu- date. Weight loss and delayed growth de- spite a hearty appetite. A brassy cough with inspiratory stri- dor.
- Which documentation further sup- ports the diagnosis of CF? Select all that apply Weight loss and delayed growth despite a hearty appetite. Pancreatic insuflciency and malabsorption are characteristic of CF and result in weight loss and delayed growth. A history of frequent respiratory infections. The respiratory system is attected by abnormally thick, sticky secretions that cause airway obstruc- A history of frequent respiratory infec- tion to the lungs. Other clinical manifestations of tions. An elevated white blood cell count (WBC). Reports of episodic abdominal pain and crying. A sweat chloride level of 35 mEq/L ( mmol/L). Bulky loose stools
- What information will the nurse in- clude when teaching about the sweat test? CF include poor growth and/or weight loss, a dry and non-productive cough, and increased bleed- ing tendencies caused by a deficiency of the fat-sol- uble vitamin K. Bulky loose stools The term for undigested fat in the stools of clients with CF is steatorrhea. The foul smell is a result of the presence of protein. Large, loose, and sticky are also terms that characterize the stools of a client with CF. It is a simple and reliable test that measures the chloride in sweat.
HESI: Cystic Fibrosis Questions and Rationale Graded A+
Informed consent will be needed for this invasive, diagnostic test. It will take 2 hours to obtain the sweat. The sweat test is a simple, painless, and reliable diagnostic test that is performed to determine the amount of chloride in the client's sweat. The sweat chloride test involves stimulating the production of sweat with a special device and collecting the This procedure will require the child to (^) sweat on filter paper, and measuring the sweat be NPO (nothing by mouth). It is a simple and reliable test that measures the chloride in sweat.
- The parents have been at the client's electrolytes. It has been the gold standard for di- agnosing CF for the past 40 years. Make arrangements to meet privately at the first bedside since she was admitted to the opportunity. hospital. The father asks to speak to the nurse outside in the hall. He tells the nurse that the mother is telling everyone that the client is going to be fine and that there has just been a mistake and everything will be all right. What action should the nurse take first? Schedule an appointment for Pamela with the hospital's chaplain. Suggest that they sit down and talk about the situation. Refer to a professional counselor. Make arrangements to meet privately at the first opportunity.
- The nurse meets to discuss the de- nial of the child's diagnosis. During the conversation, the mother final- One of the most supportive interventions for fami- lies of children with chronic health care conditions or special needs is to accept the family's emotion- al reactions to the diagnosis in a non-judgmental manner. The nurse should meet to assess the situ- ation before taking further action. "I know this has to be a very scary and diflcult time for you. What can I do to help you?" Beneficence is characterized by acts or personal
The mother shares with the nurse that I will sit with your child so you and your wife can talk. she is thinking about separating from her husband for a little while. She states that because her child has been We have a quiet room you can use that is private and close by. diagnosed with CF, she thinks she may With^ a^ diagnosis^ that^ has^ long^ term^ impacts,^ the want out of the marriage. Shortly af- ter this conversation, the nurse walks down the hall and the father asks to speak to her in private. He tells the nurse, "I saw you speaking with my wife earlier. I think she is going to leave me, and I am so scared." Based on her previous conversation with the mother, what is the best state- ment by the nurse? You are afraid your wife is going to leave you. Tell me more about what makes you think that. I will sit with your child so you and your wife can talk. We have a quiet room you can use that is private and close by. Ethically, I cannot discuss what your wife told me. Likewise, I cannot tell her what you say, either. Most parents are anxious during situ- ations like this. Would you like me to set you up with a support group?
nurse should allow the parents time to express emotions and work through feelings naturally. The parents are more likely to leave the room to deal with their crisis if they are assured that the client will not be alone.
The nurses recognize that energy needs are increased as a result of malabsorption of nutrients and that extra effort is needed for respira- tions and frequent pulmonary infec- tions. The nurse teaches the client's Pancreatic enzymes are needed to digest fats and proteins. With cystic fibrosis, the body lacks the ability to excrete the pancreatic enzymes needed to digest fats and proteins, so replacement enzymes must be parents about pancreatic replacement administered. enzymes. Which of the following state- ments by the parents would indicate a correct understanding of the teach- ing? Pancreatic enzymes are needed to di- gest fats and proteins. Pancreatic enzymes are needed until the steatorrhea stops. Administration of pancreatic enzymes will replace the need to take vitamin supplements. Pancreatic enzymes should be taken at night before bedtime.
- Which statement should the nurse record as the expected outcome for this nursing problem? The child will maintain an oxygen sat- uration level greater than 95%. The parents will list three symptoms that require notification of the HCP. The client will be able to remove mu- cus from the airway by coughing. The client will be able to remove mucus from the airway by coughing. Airway therapy is aimed at removing the mucus and moving it to large airways to be cleared. Client's ability to remove mucus or clear secretions from her airway would indicate that the outcome had been met.
Nurses' Standards of Care includes Secondary nursing includes all types of screenings primary, secondary, and tertiary nurs- to help with early intervention. ing care prevention. The student nurse asks, "What type of care is giv- en in secondary nursing care preven- tion?" Which statement by the nurse is cor- rect? "It is care such as the sweat test and DNA testing that the child received." "It includes mainly teaching informa- tion about her cystic fibrosis." "This is the nursing care we do when we are taking care of her here in the hospital." "It is care that includes giving client immunizations to prevent specific dis- eases."
- Which statement by the parents in- dicates a correct understanding of a proper nutritional protocol of a client with CF? Select all that apply Her diet should include more calories than an unaffected child. Client should use a salt substitute in place of regular table salt with her meals. Client should consume pancreatic en- Her diet should include more calories than an un- attected child. A client diagnosed with CF should consume a diet that has increased calories, protein, and fat. Client should take vitamin A, D, E, and K supplemen- tation along with her diet. It is also important that these clients take supple- mental fat-soluble vitamins of A, D, E, and K.
zymes one hour after consuming her meals. Client should take vitamin A, D, E, Her diet should consist of high fat, high protein, and unrestricted fats. and K supplementation along with her Due^ to^ the^ need^ to^ increase^ the^ client's^ caloric^ in- diet. Her diet should consist of high fat, high protein, and unrestricted fats.
- Which action indicates to the nurse educator that the parents need more instruction about the respiratory care of the child with CF complications? Placing the client in a prone posi- tion when she is having a dyspneic episode. The client's chest percussions and postural drainage should be per- formed no sooner than 1 hour before meals or 1.5 hours after meals. Encourage the parents to have client participate in physical activities such as running, skipping, and swimming. Perform the client's chest percus- sion and postural drainage after the administration of bronchodilators or nebulized medications as prescribed. take, it is best to space out the caloric intake with 3 meals/day and 2 to 3 snacks/day, in order not to overwhelm the client with too much food at one sitting and to prevent compromising pulmonary status (if the stomach is too full, putting extra pres- sure on the diaphragm). Placing the client in a prone position when she is having a dyspneic episode. Patients with dyspnea should be placed in a po- sition to promote maximum ventilatory eflciency and airway patency. The child should be placed in an upright position, not flat on the stomach, when experiencing a dyspneic episode.
pasta. Open the enzyme capsules and mix the beads in a nonprotein food. Ensure that the client swallows the pancreatic enzyme capsule whole. Ensure that enzymes are administered within 30 minutes of consuming meals and snacks
- While discussing pancreatic enzymes, the CNS explains that the dosage of the pancreatic enzyme is adjusted ac- cording to stool formation, which in- dicates how well client is digesting her food. Which adjustment would the nurse anticipate will be required, if client has constipation? The pancreatic enzymes would not be administered for 24 hours. The amount of pancreatic enzymes would be decreased at each meal. The pancreatic enzymes would be in- creased with each meal and snack. No adjustment in the dosage would be made at this time. The pancreatic enzymes would be increased with each meal and snack. Pancreatic enzymes are adjusted to decrease the bulk of the stool.
- The CNS refers the parents to the local Community resources often provide support chapter of the Cystic Fibrosis Founda- tion (CFF). Which rationale best supports this re- groups for parents of children with CF. The Cystic Fibrosis Foundation has chapters throughout the United States to provide education
ferral? Community resources often provide and services to patients and professionals. Meeting other parents who have experienced similar situa- tions can provide hope, help, encouragement, and support groups for parents of children (^) support. with CF. This foundation will provide health in- surance for children with CF. The CFF offers information on alter- native therapy and treatment modali- ties. Referrals for resources offer parents hope that a cure may one day be found.
- If the client attends a daycare center, what should be shared with the day- care workers? Select all that apply Proper handwashing between care of the other children Isolate the child from any children with upper respiratory infections Administer the enzymes in mashed potatoes twice a day Correct techniques for performing chest physiotherapy. Proper handwashing between care of the other children Children with CF are susceptible to infections and proper handwashing is important in this setting. Isolate the child from any children with upper res- piratory infections Children with CF are susceptible when around oth- ers with URIs. Correct techniques for performing chest physio- Give the client vitamins with breakfast. therapy. Children with CF should have chest physiotherapy performed routinely to prevent respiratory infec- tions.
soon as possible. The second immunization is given be- tween ages 4 and 6 years of age. The first immunization provides im- munity until adulthood. The immunization is contraindicated because of her diagnosis of cystic fi- brosis.
- Which intervention should the nurse implement first? Notify the CF nurse educator to help support the parents. Administer IV antibiotic therapy. Insert a 24 - gauge intravenous line. Administer oxygen 4L/min via high-flow nasal cannula.
- Administer oxygen 4L/min via high-flow nasal can- nula. According to Maslow's Hierarchy of Needs, oxy- genation is the priority. The clinical signs and symp- toms of hypoxia include apprehension, restless- ness, inability to concentrate, decreased level of consciousness, dizziness, and behavioral changes. The patient with hypoxia is unable to lie flat and appears both fatigued and agitated. Vital sign changes include an increased pulse rate and in- creased rate and depth of respiration. During early stages of hypoxia the blood pressure is elevated unless the condition is caused by shock. As the hypoxia worsens, the respiratory rate declines as a result of respiratory muscle fatigue. Oxygen therapy is widely available and used in a variety of settings to relieve or prevent tissue hypoxia. The goal of oxygen therapy (AARC, 2007) is to prevent or re- lieve hypoxia by delivering oxygen at concentra- tions greater than ambient air (21%).
What laboratory result warrants im- mediate intervention? Serum potassium level of 3.8 mEq/L (3.8 mmol/L). White blood cell count (WBC) is 20,000/mcL (20 x 109/L). Platelet count is 200 x 103/mcL (200 x 109/L) Serum chloride level of 101 mEq/L (101 mmol/L).
- The healthcare provider (HCP) orders gentamicin 2.5 mg/kg IV every 8 hours to be infused over 30 minutes with a peak and trough level at the second White blood cell count (WBC) is 20,000/mcL (20 x 109/L). This is an abnormal value. Normal values range 4500 to 13500/mcL (4.5 to 13.5 x 109/L). This is elevated, indicating that the client has an infection. 34 Medication to infuse within 30 minutes - > 17 mL/30 min :: (x) mL/60 min = 34 mL/60 min or 34 dose for treatment of pneumonia. The mL/hour^ is^ the^ rate^ for^ the^ syringe^ infusion^ pump pharmacy sends 17 ml of the medica- tion in a syringe to be administered.
- Two days later, the client's condition has improved, but she remains in the hospital for continued IV antibiotic therapy. The primary nurse reports to the RN charge nurse that the IV antibiotic or- dered was administered to another child and the client received the oth- to be set. Assess the client and the child who received the wrong medication. Assessment must be completed first to ensure that both children have suttered no adverse ettects from being given the wrong medication. Then the healthcare provider (HCP) should be notified so the nurse can receive follow-up instructions, and er child's ordered antibiotic. When the then,^ if^ appropriate,^ the^ correct^ medications^ can^ be primary nurse realized the mistake, the IV antibiotic was discontinued im- mediately. administered to both of the clients. A final step is the completion of an incident report.
signs. Interrupt the play therapy session to take the vital signs. Reprimand the primary nurse for de- laying the taking of the vital signs. Explain that play therapy is an inter- vention and should not be interrupted for vital signs.
- Client's pneumonia resolves. The CNS visits with the client and her parents. The parents share that they are look- ing forward to a relaxing vacation at the beach this summer. They ask the nurse educator if any special precau- tions will be necessary for her. How should the CNS respond? Wish them a happy vacation and tell them nothing special needs to be done. Suggest that they add extra salt to Darla's diet and watch her for dehy- dration. Explain that the beach is not a good vacation place for her. Encourage them to limit client's play time at the beach to 30 minutes a day. Suggest that they add extra salt to Darla's diet and watch her for dehydration. There is an increased risk for an electrolyte imbal- ance secondary to dehydration during hot weather. Drinking plenty of fluids is always necessary for people with CF, but becomes especially important during the hot, humid months of summer. Individ- uals with cystic fibrosis lose more salt (sodium chlo- ride) in their sweat than those without CF. In the summer months and during exercise, those with CF are at increased risk of becoming hyponatremic.
