NURS EXAM CASE STUDY REVIEW 2022/2023 UPDATE GUARANTEED
SUCCESS
• Mr. Davidson is a 24-year old boxer. He had a boxing game and received with a nose injury. Due
to heavy nosebleed, he was transferred to ER.
Health Assessment and Physical Exam:
Diagnostic Test:
Deviated septum is observed. X-ray is done to confirm the diagnosis.
• Patient is alert and oriented. He didn't lose his consciousness. The patient reports severe nose pain.
No other symptoms.
• Nursing Care:
• What should be your highest priority when you plan the care of this patient?
o Vent airway, BCs
• Which position should you assist the patient to and why?
o Up right position, head slightly forward
• How do you differentiate between anterior nasal bleeding and posterior nasal bleeding?
o Posterior: secondary to hypertension, older people, coughing, more dangerous, back
of throat o Anterior: stops spontaneously, not life threatening, able to see
• What are some of the nursing interventions that can help control the bleeding of this patient?
Provide rationale.
o High fowlers, pinch nose, head tilt forward, acetaminophen, nasal sponges, nasal
packing, medication for pain, Tylenol (no NSAIDS)
• What is the appropriate way to apply pressure to stop the epistaxis? How and for how long?
o Pinch nose against septum 10-15 mins, up right, lean forward, ice
• Would you insert gauze into the bleeding nostril in this case? Why? o NO because patient has a fx.
If stops in 10-15 mins then no gauze
• Considering the bleeding, what medications would be contraindicated?
o NSAIDS, (aleve, advil, ibuprofen) anticoagulants (warfarin, heparin, Lovenox)
Heparin-IV, SC Lab: aPPT Need: sulfate
,NURS EXAM CASE STUDY REVIEW 2022/2023 UPDATE GUARANTEED
SUCCESS
Coumocin- PO Lab: PT, INR Need: vit K
Lovenox-
• If you notice a clear liquid draining from the patient's left ear, what should you do next?
o Worried about CSF from skull fx, check fluid for glucose, send to lab
• What do you expect the vital signs of this patient to be? Explain.
o Increased HR, high RR, increase BP patient is in distress and anxious
• The ENT specialist applies nasal ointment that includes topical Lidocaine and epinephrine. What
are the indications and desired outcomes of these two agents?
o Lidocaine pain, epi is vasoconstrictor
• The bleeding continues, so the ENT decides to use a Pledget (nasal tampon) impregnated with cocaine.
Why cocaine?
o Cocaine- potent anesthetic and vasoconstrictor
• How long should the pledgets remain in the nose? o 2-3 days o Need ENT to place and
remove pladget
• While the pledgets inside the nose, the patient needs to sneeze, what should tell the patient? o
Sneeze with mouth open
• Remember the pre-op management (consent, precautions (bleeding and infection), etc).
o Consent- patientneeds to consent unless unconscious o Precautions- know about bleeding
and risk infection
• Formulate a nursing diagnosis with highest priority post-op.
o Airway clearance effective
o Edema
• Sulfamethoxazole/Trimethoprim (Bactrim) antibiotic was prescribed for the patient to take for 2
weeks. What teaching should you provide regarding the indication and the administration of this
antibiotic?
,NURS EXAM CASE STUDY REVIEW 2022/2023 UPDATE GUARANTEED
SUCCESS
o Finish antibiotic in entirety o Bactrim is for MRSA or staph infection During the
rhinoplasty, packing is inserted and left for few days. What teaching should you
provide regarding the packing?
o No nose blowing, swimming, heavy lifting, strenuous
activity # 2: Allergic Rhinitis
Mrs. Jones is a 32-year old who has a history of persistent allergic rhinitis.
• What is the difference between intermittent and persistent allergic rhinitis?
o Intermittent- >4 days a week or 4 months per year o Persistent-symptoms present more
than four days a week and for more than four weeks per year
• What seasons of the year do allergies flare up? Why?
o Spring and fall
• What immunoglobulin rises when Mrs. Jones exposes to allergens?
o IgE
• What are the major chemical mediators that are released during exposure to allergens? What are the
major changes these mediators cause? How do these changes explain the symptoms of sneezing,
itching, and congestion?
o Prostaglandins, leukotrienes, histamines
Release mediators,
Nursing Care:
• The best and most important step management of allergic rhinitis is to avoid allergens. Teach
the patient how to identify allergens. (Table 26-4)
• Mrs. Jones says "I want something to cure this allergy". How should you respond?
o We can manage symptoms, but not cure allergies
• Identify the connection between the chemical mediators that result from the allergic reaction and
the commonly prescribed medications.
o Histamine- antihistamines (counteract histamines released)
, NURS EXAM CASE STUDY REVIEW 2022/2023 UPDATE GUARANTEED
SUCCESS
• What is the indication, mechanism of action, desired outcome, side-effects, and adverse effects of
1stgeneration antihistamines? What is the major advantage of 2nd-generation antihistamines
compared with 1st-generation antihistamine? Mention one 1st-generation antihistamine agent
and 2ndgenerationantihistamine agent.
1st gen- Benadryl (diamahydramine)
Side effect: drowsiness –crosses blood brain barrier, sedation effect on brain
Nursing consideration: no driving
2nd Gen- Zyrtec, Claritin, allegra
Pros: non-sedative,
Con: not as strong as 1st
• How can the patient manages the dry mouth/mucosa results from antihistamines?
o Ice chips, hydration
• Flunisolide spray, an intranasal corticosteroid, is prescribed for Mrs. Jones. For the best results, when
should Mrs. Jones start using Flunisolide? o Couple weeks before allergy season o Take every day,
no prn
• Mrs. Jones says "I should take Flunisolide when I need"? How should you responds?
o False, need a few weeks to kick in
• Mrs. Jones says "Flunisolide relieves symptoms within minutes". How should you respond?
o no
• Mrs. Jones asks "I usually get a sinus infection once a year, should I continue flunisolide if I get a
sinus infection or quit?" How should you responds?
o Keep taking
• In October, Mrs. Jones' symptoms become worse and Singulair (monteLUKAST), a leukotriene
receptor antagonist inhibitor was added. Before Mrs. Jones can start using Singulair, what should the
prescriber check first?
o Liver function- AST and ALT labs
• It is safe for Mrs. Jones to use Singulair, what time of the day should she take it?
SUCCESS
• Mr. Davidson is a 24-year old boxer. He had a boxing game and received with a nose injury. Due
to heavy nosebleed, he was transferred to ER.
Health Assessment and Physical Exam:
Diagnostic Test:
Deviated septum is observed. X-ray is done to confirm the diagnosis.
• Patient is alert and oriented. He didn't lose his consciousness. The patient reports severe nose pain.
No other symptoms.
• Nursing Care:
• What should be your highest priority when you plan the care of this patient?
o Vent airway, BCs
• Which position should you assist the patient to and why?
o Up right position, head slightly forward
• How do you differentiate between anterior nasal bleeding and posterior nasal bleeding?
o Posterior: secondary to hypertension, older people, coughing, more dangerous, back
of throat o Anterior: stops spontaneously, not life threatening, able to see
• What are some of the nursing interventions that can help control the bleeding of this patient?
Provide rationale.
o High fowlers, pinch nose, head tilt forward, acetaminophen, nasal sponges, nasal
packing, medication for pain, Tylenol (no NSAIDS)
• What is the appropriate way to apply pressure to stop the epistaxis? How and for how long?
o Pinch nose against septum 10-15 mins, up right, lean forward, ice
• Would you insert gauze into the bleeding nostril in this case? Why? o NO because patient has a fx.
If stops in 10-15 mins then no gauze
• Considering the bleeding, what medications would be contraindicated?
o NSAIDS, (aleve, advil, ibuprofen) anticoagulants (warfarin, heparin, Lovenox)
Heparin-IV, SC Lab: aPPT Need: sulfate
,NURS EXAM CASE STUDY REVIEW 2022/2023 UPDATE GUARANTEED
SUCCESS
Coumocin- PO Lab: PT, INR Need: vit K
Lovenox-
• If you notice a clear liquid draining from the patient's left ear, what should you do next?
o Worried about CSF from skull fx, check fluid for glucose, send to lab
• What do you expect the vital signs of this patient to be? Explain.
o Increased HR, high RR, increase BP patient is in distress and anxious
• The ENT specialist applies nasal ointment that includes topical Lidocaine and epinephrine. What
are the indications and desired outcomes of these two agents?
o Lidocaine pain, epi is vasoconstrictor
• The bleeding continues, so the ENT decides to use a Pledget (nasal tampon) impregnated with cocaine.
Why cocaine?
o Cocaine- potent anesthetic and vasoconstrictor
• How long should the pledgets remain in the nose? o 2-3 days o Need ENT to place and
remove pladget
• While the pledgets inside the nose, the patient needs to sneeze, what should tell the patient? o
Sneeze with mouth open
• Remember the pre-op management (consent, precautions (bleeding and infection), etc).
o Consent- patientneeds to consent unless unconscious o Precautions- know about bleeding
and risk infection
• Formulate a nursing diagnosis with highest priority post-op.
o Airway clearance effective
o Edema
• Sulfamethoxazole/Trimethoprim (Bactrim) antibiotic was prescribed for the patient to take for 2
weeks. What teaching should you provide regarding the indication and the administration of this
antibiotic?
,NURS EXAM CASE STUDY REVIEW 2022/2023 UPDATE GUARANTEED
SUCCESS
o Finish antibiotic in entirety o Bactrim is for MRSA or staph infection During the
rhinoplasty, packing is inserted and left for few days. What teaching should you
provide regarding the packing?
o No nose blowing, swimming, heavy lifting, strenuous
activity # 2: Allergic Rhinitis
Mrs. Jones is a 32-year old who has a history of persistent allergic rhinitis.
• What is the difference between intermittent and persistent allergic rhinitis?
o Intermittent- >4 days a week or 4 months per year o Persistent-symptoms present more
than four days a week and for more than four weeks per year
• What seasons of the year do allergies flare up? Why?
o Spring and fall
• What immunoglobulin rises when Mrs. Jones exposes to allergens?
o IgE
• What are the major chemical mediators that are released during exposure to allergens? What are the
major changes these mediators cause? How do these changes explain the symptoms of sneezing,
itching, and congestion?
o Prostaglandins, leukotrienes, histamines
Release mediators,
Nursing Care:
• The best and most important step management of allergic rhinitis is to avoid allergens. Teach
the patient how to identify allergens. (Table 26-4)
• Mrs. Jones says "I want something to cure this allergy". How should you respond?
o We can manage symptoms, but not cure allergies
• Identify the connection between the chemical mediators that result from the allergic reaction and
the commonly prescribed medications.
o Histamine- antihistamines (counteract histamines released)
, NURS EXAM CASE STUDY REVIEW 2022/2023 UPDATE GUARANTEED
SUCCESS
• What is the indication, mechanism of action, desired outcome, side-effects, and adverse effects of
1stgeneration antihistamines? What is the major advantage of 2nd-generation antihistamines
compared with 1st-generation antihistamine? Mention one 1st-generation antihistamine agent
and 2ndgenerationantihistamine agent.
1st gen- Benadryl (diamahydramine)
Side effect: drowsiness –crosses blood brain barrier, sedation effect on brain
Nursing consideration: no driving
2nd Gen- Zyrtec, Claritin, allegra
Pros: non-sedative,
Con: not as strong as 1st
• How can the patient manages the dry mouth/mucosa results from antihistamines?
o Ice chips, hydration
• Flunisolide spray, an intranasal corticosteroid, is prescribed for Mrs. Jones. For the best results, when
should Mrs. Jones start using Flunisolide? o Couple weeks before allergy season o Take every day,
no prn
• Mrs. Jones says "I should take Flunisolide when I need"? How should you responds?
o False, need a few weeks to kick in
• Mrs. Jones says "Flunisolide relieves symptoms within minutes". How should you respond?
o no
• Mrs. Jones asks "I usually get a sinus infection once a year, should I continue flunisolide if I get a
sinus infection or quit?" How should you responds?
o Keep taking
• In October, Mrs. Jones' symptoms become worse and Singulair (monteLUKAST), a leukotriene
receptor antagonist inhibitor was added. Before Mrs. Jones can start using Singulair, what should the
prescriber check first?
o Liver function- AST and ALT labs
• It is safe for Mrs. Jones to use Singulair, what time of the day should she take it?
