You are admitting a 19-year old female college student to the hospital for fevers. Using the patient information provided, choose a culture unfamiliar to you and describe what would be important to remember while you interview this patient. Discuss the health care support systems available in your community for someone of this culture. If no support systems are available in your community, identify a national resource.

a. Alice is 27-year old female who is five months pregnant. She is undergoing a dermatological procedure requiring local anaesthesia. Her medical history reports the following: allergic to eggs; taking ranitidine for gastric reflux; taking pyridoxine and doxylamine for nausea; history of scoline apnoea, thrombocytopaenia, and gestational diabetes. Her doctor has decided to use tetracaine with felypressin. Discuss the appropriateness of the anaesthetic combination.

b. During a routine check-up at her obstetrician, Alice is made aware that her blood pressure is 145/98 mm/Hg. Follow-up measurements are done, and her blood pressure remains high. Her doctor wishes to prescribe either carvedilol, valsartan, hydralazine, or α-methyldopa as an anti-hypertensive. Given her presentation, i) suggest an appropriate anti-hypertensive to use from those mentioned, ii) justify your selection by referring to the inappropriateness of the other options, and iii) explain how your suggested drug reduces blood pressure.

Choose or imagine an organization that is highly differentiated but not highly integrated. What are some benefits of such a structure?

Compare and contrast tall and flat hierarchies. Explain when it might be more appropriate to use one form of hierarchy over the other.

Describe the benefits of informal groups, how they are formed, and ways groups create their own identity.

We have all had supervisors that we thought could do a better job at managing their staff and we also hope to be better managers than what we have experienced at certain places of employment. Discuss the following with your classmates and instructors.

How should employees relate to supervisors who are inaccessible and who hoard information? What can employees do about this type of supervisor?

What characteristics are present in an individual with leadership potential?

Part 1

Critical Thinking Case Study: Delayed Pushing in Second Stage Labor from text page 428:

A nurse is assigned to care for Emily, a 25-year-old G1 P0 at 39 weeks of gestation. The nurse has just performed a vaginal examination and found that Emily's cervix is completely dilated. She has an epidural, which is working well. Currently Emily is feeling neither pressure nor pain. On learning that Emily's cervix is completely dilated, her health care provider exclaims (not the nurse), “Good! Get in there and help her push so we can have this baby! I'm ready to go home. I've had a long day!” Provide EB rationale for all responses.

1.      Evidence—Is there sufficient evidence to draw conclusions about effective management of second-stage labor?

2.      Assumptions—Describe an underlying assumption about each of the following issues:

a.       Delayed pushing

b.      Positioning for pushing

c.       Spontaneous versus directed pushing efforts

3.      What implications and priorities for nursing care can be drawn at this time?

4.      Does the evidence objectively support your argument (conclusion)?

Part 2

  Question: Answer the following questions and provide rationale for the answer choice:

A primigravida is pushing with contractions. The nurse notes that the woman’s perineum is beginning to bulge and that there is an increase in bloody show. Which of the following actions be the nurse is appropriate at this time?   

a)      Report the findings to the patient’s health care practitioner

b)      Immediately assess the client’s pulse and blood pressure

c)      Provide encouragement during each contraction

d)      Place the client on her side with oxygen mask at 8 liters/min

Why does inhibition of ADH result in increased serum osmolarity?

a. Jasper has been admitted to the emergency room after experiencing a myocardial infarction. His electrocardiogram displayed significant elevation of the ST-segment, and his biochemical work identified the release of cardiac enzymes and normoxia. He required pharmacological and percutaneous intervention. Discuss the appropriateness of administration of the following treatments to him: isosorbide dinitrate, oxygen, and anistreplase.

b. While in the hospital, Jasper develops arrythmias. His doctor prescribes lidocaine for the treatment thereof. Explain i) how lidocaine decreases arrythmias, and ii) which route of administration would be used and why.

Discuss the importance of food safety and sanitation and the impact on GI health. Give an example of a disease ( GI ailment) which can be attributable to improper food handling. Describe signs, symptoms and treatment.

Five page scholars paper on cutting healthcare cost and cost effectiveness of generic drug use. With five references and five scholarly peer-reviewed articles accompanied by a brief summary of each article.

Case Study – AbdomenPresentation/HistoryA 33-year-old medical secretary comes to the physician's office complaining of nausea and vomiting of bile-stained food, with sensations of bloating, belching, discomfort, and pain in the upper abdomen. These symptoms come on approximately one to two hours after meals. Following a respiratory infection she suffered a marked weight loss amounting to twenty-five pounds during the last six months. Since then her symptoms have gradually worsened.On inquiry she states that since adolescence she has had alternating periods of well-being and abdominal discomfort accompanied by vomiting. Since the recent aggravation of her symptoms, she has felt very fatigued and has lost her appetite. She further states that when she has these attacks of pain and vomiting she can obtain relief by lying on her side or in the knee-chest position.ExaminationOn physical examination we find a rather apprehensive patient of asthenic habitus, particularly conspicuous since she shows evidence of recent marked weight loss. She has very flaccid abdominal walls and her liver, kidneys, and spleen can be palpated easily. As is common in asthenic individuals, she has a marked lumbar lordosis. The epigastrium is rather tender, but otherwise no signs of acute intestinal illness, such as rigidity of the abdominal wall or indications of intestinal obstruction, can be elicited. The patient is advised to seek admittance to the hospital for further studies.In the hospital a full-blown attack is observed, which came on after a fairly large meal with a meat course and dessert. She was stricken with nausea and fairly severe cramping pain in the right upper abdominal quadrant. She vomited bile-stained food that she had eaten recently. The vomiting relieved her pain. Before the attack subsided, the examining physician noted that the patient displayed tenderness and visible peristalsis in the right upper abdominal region.Radiographic study of the upright patient under the fluoroscope with a radiopaque meal shows rapid emptying of the stomach, which permits exclusion of pyloric stenosis. The first three portions of the duodenum fill rapidly and are considerably dilated. Under active peristalsis the duodenum finally empties part of the barium into its fourth portion, but there is marked indentation of the barium filling at the site of transition of the third and fourth lumbar vertebrae. This corresponds to the cutoff point at the time of the beginning of filling of the duodenum. X-ray examination six hours after the barium meal shows a marked and abnormal residue of barium in the duodenum.DiscussionObstruction of the third portion of the duodenum as a clinical entity is an interesting phenomenon. Enthusiasm for this diagnosis has waxed and waned since the disease was first defined in the mid-1800’s. There are still authors who deny the occurrence of such an entity, but the majority of clinicians are now convinced of its existence, particularly when confirmed by radiographic evidence. Anatomists and pathologists have known for a long time that postmortem casts of the duodenum frequently show an imprint of the superior mesenteric vessels on the anterior wall of its third part. The equivalent of this imprint has been demonstrated in vivo by radiologic means as a filling defect in the same location.1) Describe the position of the parietal peritoneum, transverse colon, mesocolon, pancreas, aorta, and superior mesenteric vessels in relation to the third part of the duodenum (9).It can be palpated to the right of the mesenteric root. This part of the duodenum, which is also often called the inferior or horizontal portion, is about three inches in length. It begins at the inferior duodenal flexure as the continuation of the descending portion and generally crosses the third lumbar vertebra. At its left extremity it becomes the fourth or ascending portion that terminates as the duodenojejunal flexure.The mesenteric vessels pass over the third part of the duodenum to enter the mesentery and to supply the small and large intestines from the distal duodenum to the left colic flexure. The superior mesenteric vein drains the same area of intestine and courses to the right of the artery. Their relationship to each other is easy to remember if one keeps in mind that the artery arises from the aorta in the midsagittal plane while the vein drains into the portal vein in its course toward the liver which is essentially a right-sided organ.

2) Trace the course of the superior mesenteric artery from the aorta as it wraps around the pancreas (4).In its course, the artery is surrounded by the superior mesenteric nerve plexus. Since the artery runs posterior to the neck of the pancreas it is, of course, also posterior to the transverse mesocolon which arises from the anterior surface of the pancreas. It is worthwhile to keep in mind that, while the origin of the superior mesenteric artery is cranial to the third portion of the duodenum, the origin of the inferior mesenteric artery is caudal to this part of the duodenum. It is also easy to remember that the superior and inferior mesenteric veins, which accompany the two mesenteric arteries both lie to the outside of the arteries, i.e. closer to the lateral abdominal wall than the arteries. Since the duodenum, with the exception of its first portion, is a retroperitoneal structure, its position is less variable than organs having a mesentery. Nevertheless, it is surprising to observe that the duodenum is relatively mobile in vivo. Its location varies with body posture being lowest in the upright and highest in the prone position. It also changes with the degree of its filling and the state of contraction of the anterior abdominal wall. It descends with age. Thus, the level of the third lumbar vertebra or of the disk caudal to it, represents only a mean as a landmark for locating the third portion of the duodenum, with the range extending from L2 to L5.3) Complete the following embryologic migration of these structures, explaining the eventual retroperitoneal position of the major part of the duodenum and the retrovascular location of the third portion of this viscus in relation to the super mesenteric vessels (9). The intestinal tube forms an__________ convex loop in the __________plane and is suspended from the wall of the abdomen by a mesentery. The tube then rapidly increases in __________ and undergoes a rotation by __________ degrees, with the superior mesenteric artery acting as the axis of __________. The superior mesenteric artery comes to lie __________ to the duodenum but __________ to the transverse colon.The cardinal point of this discussion is, of course, the pathogenesis of the clinical entity exemplified by our patient. While normally the superior mesenteric vessels pass gently over the third part of the duodenum, in our case we have to visualize the transverse duodenum as being markedly compressed, as in a vise, between the aorta and/or lordotic vertebral column posteriorly and the taut mesenteric vessels anteriorly. This happens if, due to severe weight loss in an asthenic patient with insufficient abdominal muscular support, the intestines drop caudally to an undue degree. Thus, marked traction is exerted on the superior mesenteric vessels at the site of the mesenteric root. This can lead to acute or intermittent chronic obstruction of the duodenum at this level.4) Describe what is meant by the term " asthenic habitus," so well demonstrated by this patient (1).5) Give an anatomic explanation for the symptoms of the patient in the acute stages of her illness (3). 6) Speculate as to the reason for the intermittent occurrence of her attacks with free intervals in between (2).The x-ray examination of the patient reveals, in addition to the dilatation of the duodenum proximal to the obstruction, increased peristalsis leading to emptying of the duodenum through the duodenojejunal flexure. Records of other cases also show hypertrophy of the duodenal musculature with dilation proximal to the obstruction. It is understandable that incomplete constriction can become complete with exhaustion of the propelling musculature force. We then face an acute, life-threatening clinical picture that requires immediate surgery. The recent aggravation of all symptoms in the patient is due to severe loss of weight and increased flaccidity of her abdominal musculature. The weight loss has resulted in diminution of the fat cushion in the mesenteric root that so far had protected the duodenum from complete and lasting compression. The accompanying loss of fat in the pelvis, greater omentum, and retroperitoneal structures, and the weakening of her abdominal musculature, has led to further sagging of the intestines into the pelvis and an increase of the drag on the mesenteric vessels. This further decreases the acute angle between aorta and superior mesenteric artery, a process that has been compared with the action of a nutcracker clamping down on the third part of the duodenum. Clinicians and radiologists have reported that manual pressure on the lower abdomen in a cephalic direction with the patient in the supine position will relieve the retention by lifting the intestine out of the true pelvis. Pathologists have obtained similar results at autopsy by raising the viscera after opening of the peritoneal cavity, and have observed the passage of liquid contents or air beyond the point of obstruction after this maneuver.7) Identify two additional factors that may contribute to arteriomesenteric occlusion by tightening the vise on the inferior part of the duodenum (2).

The APRN is assessing a patient that is talking to his mother in the corner of the room even although you are the only other person in the room. This is an example of:

Delusion

Hallucination

Anhedonia

Pressured speech

The Interpersonal Communication Continuum

Explain how you interpret the statement, "Interpersonal communication exists along a continuum." Have you ever engaged in communication with someone who wanted to be more personal than you wanted to be? How about less? How did you handle the situation? What are your own guidelines for interpersonal communication in the workplace?