A forty-five-year-old man with a three-year history of cardiovascular disease has entered the hospital with a stroke that has paralyzed his right side and caused him to aspirate food of any consistency. His mental status is clouded and there is disagreement as to whether or not he has decisional capacity. His language capacity is only “yes” and “no,” and his responses are inconsistent. The attending physician is convinced that the patient has lost decisional capacity while two family members are equally convinced that he has decisional capacity. The patient’s wife and two other children are ambivalent about his competency to make decisions. The prognosis for recovery of safe swallowing and speech approaches zero because of the dense damage to the cerebral cortex visible on brain imaging. Two neurological consultants have verified that recovery is likely to be minimal and that permanent, severe disability will be the outcome.

The patient does not have an advance directive. The patient’s wife says that they never did discuss his preferences about life-sustaining treatment. She is convinced that he would not want to live in this disabled condition, but is uncertain whether to request the placement of a feeding tube. Two of her four adult children are strongly opposed to the tube placement, while the other two insist that not to do so would be to “kill our father.” The patient’s wife is torn between these two positions, but finally requests that the tube be placed.

The attending physician and the rest of the treatment team are opposed to placing the feeding tube. Their argument is that the patient has “minimal consciousness” and will not improve. They define this as a futile situation with no reasonable expectation of recovery. Furthermore, two nurses claim that during previous hospitalizations for episodes of cardiovascular events the patient told them that he would not want to be sustained by artificial means — not by ventilators, renal dialysis, or tube feeding. It is their position that the patient has expressed his preference to not be kept alive in a futile situation.

The family requests an ethics consultation.

1. The family is divided over whether or not their husband/father should be placed on a feeding tube.

If the husband is deemed competent, who makes the final decision? _________

If not competent, who is the husbands’ official surrogate? ___________

The burdens the treatment (feeding tube) imposes should not be a consideration for the adult children? True_________ False _________

Ethics committees play an advisory role? True _______ False______

Ethics committees act as advocates for the healthcare team? True______ False ________

Decisions of ethics committee are legally binding? True____ False____

Please briefly answer/discuss the following:

The judgment of futility should be a conclusion of a communications process, not a beginning. How would you propose beginning the communication process with the family in this case?

First consider, what is the purpose of an ethics committee?

What information should be shared?

Who should be present?

What alternatives are on the table in this case?

Should the nurses’ statements be considered?

As part of the healthcare team, what is your goal in participating in the discussion?

Gerry pays $W to buy a ten-year annuity with end-of-year payments of $1,400. This purchase price allows her to replace her capital by means of a savings account that has an annual effective interest rate of 3% and also to earn an overall annual yield of 6% for the ten years of the annuity. Find W.? The answer is 9508.9. Please show steps to the answer without use of excel.

Jan is a 75-year old woman who has lost significant weight in the last year. She has complaints of anorexia and joint pain. She states she just doesn’t feel like eating sometimes. She has had significant constipation causing hemorrhoids and states it is very difficult to stool.

- What other medical history is necessary in order to effectively treat Jan?

- What education might be helpful?

- What are complications you might consider?

- What therapies might benefit Jan's health?

Emma is a 12-year-old girl enrolled in year 7 at a local state high school. Since commencing high school this year, Emma’s academic results have dropped significantly over the past 9 months from an A to a C level student. She has lost interest in completing schoolwork and participates little in class. She regularly misses days from school and when she is there, frequently isolates herself at break times and asks to go home as she is feeling ill. Teachers have spoken to you as the School Based Youth Health Nurse regarding Emma’s wellbeing. They are concerned as to whether there may be any physical or mental health issues impacting Emma’s presentation at school. After speaking with Emma’s mother to obtain the background case history information detailed below, you consult the School Guidance Officer who refers Emma to the local Child and Youth Mental Health Service (CYMHS), requesting COPMI support and investigation of potential anxiety disorder.

Demographic information
Emma lives with her mother Julie, aged 29 and younger sister Ariella, aged 9. Julie’s husband Paul is aged 32 and works as a Fly in Fly out (FIFO) miner who spends 2 weeks away then 2 weeks back in town. Paul lives separately, about 15 minutes’ drive away, after acrimoniously separating from Julie for a second time, 9 months ago. Despite Paul being in town for 2 full weeks at a time, he has been unpredictable in his contact with both Emma and Ariella. Julie reports that Paul will often turn up to her house at odd hours before school or in the evening, demanding to see the girls. He will yell and argue loudly with Julie about child support payments and contact with the girls whilst his daughters remain inside the house. To cope with this stressful contact, lack of nearby family support and financial worries caused by unemployment, Julie self-medicates with a combination of alcohol and medications. On one occasion after school, Emma found her mother unconscious as a result of overdose. Emma later overheard paramedics say that if she hadn’t called 000 when she did, her mother would have died.

In your discussion with Julie, she describes spending her childhood in a regional town however she left home at 15 years of age as a result of her own parent’s separation and divorce following paternal alcohol problems. Julie has had limited contact with her parents and younger sister since that time. She described feeling highly anxious during her teenage years whilst living on the streets. To cope with her anxiety, she engaged in substance misuse for 18 months before falling pregnant with Emma. Whilst pregnant with Emma, she met Paul and soon married him. For a short time, Julie and Paul lived with Paul’s parents in the regional town however Paul’s father was frequently verbally and physically aggressive towards them so they moved to the city in the hope that Paul could have improved employment opportunities. Two years later, Julie fell pregnant with Ariella who is Paul’s only biological child. Paul has made it clear to Emma from a young age that she is not his child and that he prefers to spend time with Ariella. Emma has never met her biological father as Julie has had no contact with him since informing him of her pregnancy with Emma. Emma is described by her mother as mature for her age, with a shy, sensitive and caring nature. She has a small group of close friends who she has maintained regular contact with up until the last 6 months. Since then, Emma has preferred to come home and spend time in her room despite regular invitations to visit friends after school and stay for sleepovers. From the age of 8 years onwards, Emma has had a love of netball, regularly attending all weekly practice sessions and weekend games. However, at the start of this netball season Emma has only attended sporadic practices and games, preferring to stay at home with her mother and sister. Julie reported that Emma has more recently complained of feelingsick before school and frequently asks to stay home. Julie explains that she has allowed this to occur on several occasions, particularly when she is stressed knowing Paul is home from his FIFO work.

1. Emma is aged 12. Identify the developmental (biological and psychological) issuesto be considered by the nurse when caring for Emma;
2. Relate information in Emma’s history to known factors associated with risk of mental illness in adolescents;
3. List the potential impacts for Emma related to her schooling and social interactionsif she and her mother are not engaged with mental health services? Summarise strategies mental health nurses can implement to engage with the family;
4. Outline methods the mental health nurse, aware of the potential for re-traumatisationand the reality that ongoing trauma may still be present in their life experience, will use to build trustwith Emma and her mother;
5. Review the HEEADSSS assessment tooland the MSE for children: Write two questionsyou would pose to Emma about school and netball(education, activities: alone and with peers)– to engage Emma in conversation(speech, concept of self/others, positive attributes).
6. Complete a risk assessment(see table on the last page of this document);
7. Emma has a provisional diagnosis of anxiety. In the context of child and youth mental health services, outline the aim of early intervention.  Summarise the pharmacologic and non-pharmacologic approachesto care and identify referral and support pathways to other health care professionals and services.

1. Interpret the tables trend year by year comparing both company?

Hampton Industries had $57,000 in cash at year-end 2017 and $20,000 in cash at year-end 2018. The firm invested in property, plant, and equipment totaling $140,000. Cash flow from financing activities totaled +$230,000. Round your answers to the nearest dollar, if necessary.

1. What was the cash flow from operating activities? Cash outflow, if any, should be indicated by a minus sign.
   $  
   
2. If accruals increased by $15,000, receivables and inventories increased by $195,000, and depreciation and amortization totaled $25,000, what was the firm's net income?
   $  

In its first year of operations, your company's income tax expense was $40,000, and your year-end income taxes payable came to $40,000. Explain what happened here.

Walmart has an interest in monitoring the average back-to-school spending for grade-school students year to year. Every year the back-to-school spending data is published by the National Retail Federation. The following table shows the average back-to-school spending of households randomly sampled in 2016 and 2017 along with the population standard deviations and sample sizes for each sample.
2016 2017
Sample mean $606.40 $655.27
Sample size 35 38
Population standard deviation $160 $173
a. State the correct null and alternative hypotheses.



b. Perform a hypothesis test using α = 0.10 to determine if the average household back-to-school spending in 2016 was different than it was in 2017.







c. Use Confidence Interval to test this hypotheses