According to Fouka & Mantzorou ( 2011) It is said that ethics is the branch of philosophy which deals with the dynamics of decision making concerning what is right and wrong (Fouka & Mantzorou, 2011, p. 4). As a nurse we are advocates to our patients and must have respect for all and provide care in a dignified manner. When nurses participate in research they have to cope with three value systems, society, nursing and science (Fouka & Mantzorou, 2011, p. 4).
Significant Ethical Issues
Ethical consideration tells us how we should conduct research, legal guidelines tell us how we are required to conduct research (Houser, 2018, p. 50). When planning a research project it is important to consider if any harm will come to the participants, and the researcher should evaluate the possible harms and then have those potential harms removed.
Research with vulnerable populations is just one ethical issue one might face as a researcher. Persons with diminished autonomy sometimes are regarded as vulnerable or as a member of the vulnerable population, and these groups may contain some individuals who possess limited autonomy ( that is, they cannot fully participate in the consent process) for example children, individuals with dementia and other cognitive disorders, prisoners and pregnant women (Houser, 2018, p. 55).
Research of minors falls into the category of a vulnerable population and when proposing a research study with children as participants, the Institutional Review Board (IRB) has to consider what the potential risks, benefits and pain or discomfort the child participant might have. In assessing the risks and potential benefits the IRB should consider the circumstances of the children to be enrolled in the study-for example their health status, age and ability to understand what is involved in the research as well as potential benefits to subjects, other children with the same disease or condition, or society as a whole (“Children,” 2016, para. 3). What happens when the research is on sexual health? All states and Washington, DC have laws in place that allow minors to seek care and consent for themselves regarding their own sexual health. Of the 50 states and DC, there are 31 states that will allow for the minor to consent for HIV and STI treatment and prevention. Despite these supportive HIV/STI care access policies for youth, and an ethical context that supports HIV/STI prevention, controversy about parental permission and minors “ maturity” remain in research (Brawner & Sutton, 2018, p. 545).
Another ethical issue in research is the matter of privacy and confidentiality. Privacy is the control over the extent, timing and circumstances of sharing oneself ( physically, behaviorally or intellectuality) with others and confidentiality pertains to the treatment of information that an individual has disclosed in a relationship of trust and with the expectation that it will not be divulged to others without permission in ways that are inconsistent with the understanding of the original disclosure (“Privacy,” 2019, para. 6). Protocols should be implemented that allows for minimal identification about the research participants and for privacy it is essential to look into culture norms as some cultures are more private than others.
How do these issues compare to issues already seen in nursing practice
For most of my career I worked in an inner-city academic facility and every shift the medical and nursing staff wrestled with informed consent where minors were concerned. A young girl could present to the ER to be tested for STIs and pregnancy and would be able to consent for herself. The dilemma came into play when the pregnancy test was positive. She is a minor, she is able to consent for herself but how was I, a RN morally and ethically leave that ER without notifying her parent. It was situations like this where social services would be called in. The facility has a social worker assigned to the ER 24 hours a day, 7 days a week. This issue was not a one off, it happened on most shifts that I worked.
Providing privacy and maintaining confidentiality for patients is something that everyone working in healthcare has to do. We all take classes in HIPPA and have patients sign a confidentiality form stating that we will not disclose their medical information to anyone that is not listed on their privacy form. In the community clinic we do this for every patient at every visit. At times maintaining confidentiality seems futile because the clinic is an a very small rural area where everyone seems to know each other, but as futile as it seems the clinic does an excellent job of providing confidentiality.
References
Brawner, B. M., & Sutton, M. Y. (2018). Sexual health research among youth representing minority populations: To waive or not to waive parental consent. Ethics & Behavior, 28(7), 544-559. http://dx.doi.org/10.1080/10508422.2017.1365303
Fouka, G., & Mantzorou, M. (2011). What are the major ethical issues in conducting research? Is there a conflict between the research ethics and the nature of nursing? Health Sciences Journal, 5(1), 3-14. Retrieved from https://search-proquest-com.ezp.waldenulibrary.org/docview/845921674/fulltextPDF/54E10B7826584C16PQ/1?accountid=14872
Houser, J. (2018). Nursing Research. Reading, Using and Creating Evidence (4 ed.). Burlington, MA: Jones & Bartlett Learning.
Privacy and confidentiality. (2019). Retrieved from https://www.research.uci.edu/compliance/human-research-protections/researchers/privacy-and-confidentiality.html
Special protections for children as research subjects. (2016). Retrieved from https://www.hhs.gov/ohrp/regulations-and-policy/guidance/special-protections-for-children/index.html
 
POST 2
Lodian T
Ethical Issues Relevant to the DNP- or PhD-Prepared Nurse
Ethical issues in clinical practice are increasingly problematic for nurses in almost all disciplines. As nurses, one encounters ethical challenges from being an administrator’s nurse to a bedside nurse or even advanced practice registered nurse. Nurses sometimes are often uncomfortable in addressing certain ethical issues they encounter in patient care. Some of the ethical challenges the DNP and Ph.D. prepared nurse faces are professionals, patient confidentiality breaches, right to privacy, and end-of-life decision-making (Larkin et al., 2019). The decision making on how resources are spent in managing a particular illness poses a moral issue. The decisions and choices about which medications and treatment options may prolong a patient life is an ethical dilemma frequently encountered (Haahr et al., 2020). The fact is, at times, some patients are not in a position to afford some of these treatments.
The nursing shortage and staffing inadequacies create a stressful and ethical issue. Without adequate staffing, it is challenging to meet professional practice’s ethical standards (Larkin et al., 2019). Understaffing creates systematic stress on organizations and on many nurses trying to meet each patient’s needs. The primary responsibility of protecting each patient’s rights is a challenge every day as deciding whom to care for first sometimes poses an ethical issue. As we know, today’s healthcare environment is driven by demands in providing high-quality care and managing costs. Yet, nurses seem to be doing more and more with limited staffing and having to questions the care at times provided as not adequate.
Issue Encountered in Practice
The ethical principle of respect involves understanding the differences of opinion of a patient and their families. The ethical challenges encountered depend on the nurse’s role (Sabone et al., 2020). The daily pressure of caring for patients with an advanced illness poses a challenge when deciding which care a patient should receive. According to Mehdipour-Rabori et al. (2019), ethical issues occur in healthcare every day where the profound moral of right or wrong comes into question and underlines the professional decision-making that benefits the patients. For instance, as a critical care nurse, one often faces suffering head-on and might question the balance between the value of attempts to preserve a patient’s life. This, to many, may appear as prolonging anguish and yield no beneficial outcome. Naturally, all healthcare team members, including nurses, can be affected by ethical decisions. Addressing ethical issues sometimes can prove to be exhausting when trying to work through ethical problems.
Another issue is the end of life care. Haahr et al. (2020) cited far too often, end-of-life ethical issues are not thoroughly discussed with care teams or families, which creates a stressful environment when providing care. Jakobsen and Sorlie (2016) state as the healthcare system continues to change, other ethical issues of importance may need to be explored. Of course, ethical issues will differ depending on the practice setting, patient population, and needs within society.
References
Haahr, A., Norlyk, A., Martinsen, B., & Dreyer, P. (2020). Nurses experiences of ethical dilemmas: A review. Nursing Ethics, 27, 258-272. https://doi.org/10.1177/096973 3019832941
Jakobsen, R., & Sorlie, V. (2016). Ethical challenges. Nursing Ethics, 23, 636-645. https://doi.org/10.1177/0969733015580810
Larkin, M. E., Beardslee, B., Cagliero, E., Griffith, C. A., Milaszewski, K., Mugford, M. T., Myerson, J. M., Ni, W., Perry, D. J., Winkler, S., & Witte, E. R. (2019). Ethical challenges experienced by clinical research nurses: A qualitative study. Nursing Ethics, 26, 172-184. https://doi.org/10.1177/0969733017693441
Mehdipour-Rabori, R., Dehghan, M., & Nematollahi, M. (2019). Nursing students’ ethical challenges in the clinical settings: A mixed-methods study. Nursing Ethics, 26, 1983-1991. https://doi.org/10.1177/0969733018810766
Sabone, M., Mazonde, P., Cainelli, F., Maitshoko, M., Joseph, R., Shayo, J., Morris, B., Muecke, M., Wall, B. M., Hoke, L., Peng, L., Mooney-Doyle, K., & Ulrich, C. M. (2020). Everyday ethical challenges of nurse-physician collaboration. Nursing Ethics, 27, 206-220. https://doi.org/10.1177/0969733019840753
 
POST 3
Nichole C
Theoretical Framework for a Practice Problem
The article, ‘The gut microbiome in coronary artery disease and heart failure: Current knowledge and future directions,’ links sequenced-altered gut microbiota to cardiovascular disease. If understanding how altered gut bacteria triggers cardiovascular disease then the knowledge gained may improve clinical practice for CAD and heart failure patients. This research article does not address the “how-to” of a practice problem but identifies a knowledge gap in the understanding of the gut-heart connection and contributes to building a nurse’s body of knowledge (Gray, Grove, & Sutherland, 2017). There is no identified nursing theory the authors of the article use to guide their research. They use genetic sequencing and bioinformatics methodologies to comprise a gut microbiome profile with the active metabolites and their function and how they impact cardiovascular structure and function (Trøseid, Andersen, Broch, & Hov, 2020).
Insights into Quality-of-Life Theory
The nursing framework I used was the Quality-of-Life theory to help me understand the gut-heart axis phenomenon. Based on a synthesis of five nurse scholars’ theories, the Quality-of-Life theory can be defined as an intangible, subjective perception of one’s lived experience (Plummer & Molzahn, 2009). This definition is appropriate for contemporary nursing in that it embraces a perspective in which aspects of quality of life are intertwined and not divisible into discrete parts like health theory (Plummer & Molzahn, 2009). The Quality-of-Life theory encompasses the nursing practice involving care for the whole persons and their environment, rather than selected parts of their health (usually the physical aspect when talking about health). The Quality-of-Life theory is important to nursing knowledge development because it guides the art of practice.
Application of Theory
I think this theory can guide quality research for the gut-heart axis concept but since the research didn’t start with a solid nursing theory it was difficult to apply the theory afterwards. When researchers communicate clearly about how a theory was applied in their studies, others can synthesize evidence more readily across studies where the same theory was used, and by doing so, researchers can build scientific knowledge more efficiently than if they were not theory guided (Lor, Backonja, & Lauver, 2017). I believe the Quality-of-Life theory allows nurses to build a framework that is critical in producing the best evidence-based research. As nurse researchers, we must translate the best evidenced-based research into clinical practice so we can improve the quality of life for our patients.
References
Gray, J.R., Grove, S.K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Saunders Elsevier.
Lor, M., Backonja, U., & Lauver, D. R. (2017). How could nurse researchers apply theory to generate knowledge more efficiently?. Journal of Nursing Scholarship, 49(5), 580-589.
Plummer, M., & Molzahn, A. (2009). Quality of life in contemporary nursing theory: A concept analysis. Nursing Science Quarterly, 22(2), 134-140.
Trøseid, M., Andersen, G. Ø., Broch, K., & Hov, J. R. (2020). The gut microbiome in coronary artery disease and heart failure: Current knowledge and future directions. EBioMedicine, 52, 102649.
 
POST 4
Pamela J
Theoretical Framework
The key concepts are defined in this writer’s research by a theoretical framework, examines relations between the concepts, and, based on the literature review, discusses relevant theories (Gray et al., 2197). This framework is critical and is present in qualitative, quantitative, or mixed methods (Gray et al., 2017).
Article Identified
A Blueprint for Leadership During Covid-19: Minimizing Burnout and Moral Distress among the Nursing Workforce (Rosa et al., 2020) is an article chosen to look at nursing burnout during the ongoing pandemic. The nursing workforce is exposed to increased stressors that lead to burnout, including; limited resources, increased job expectations, and increasing spiritual, mental, emotional, and physical distress and exhaustion. The primary cause of burnout is a poor work environment characterized by job demands outweighing resources. Burnout in nursing is linked to absenteeism, turnover, depression, job dissatisfaction, and even suicidal ideation (Rosa et al., 2020).
This article enlightened these changing practice considerations: more work, fear surrounding safety and health, isolation, threats to livelihoods, risk or redeployment, and the unknown, unclear, and uninformed, new technology, and rising moral residue (Rosa et al., 2020). Needed changes for the rapid and intelligent investment in nursing at the levels of policy and leadership to optimize strategic workforce in all specialties and levels.
Theoretical Framework Selection Used
The components to review when beginning research include assumptions, operational concepts, and theory or model relationships (Gray et al., 2017). The framework used for supporting a research study’s theory is developing the hypothesis, a frame of reference for observation, concept definitions, research designs, interpreting, and generalizations. It serves as a guide to systematically identify relationships among variables (Weld et al., 2008).
Research Framework
As applied to nursing burnout during the pandemic of Covid-19, the research framework is appropriate. It looks at the different stressors and changes throughout the nursing care of patients in real-time. Wellness initiatives evaluated to reduce nursing burnout and maintain healthy staff. Databases provide platforms for systemic research, including Medline, CINAHL, PRESPERO, and others.
Insights Gained
The problems acquired during Covid-19 provide insight into the neglect of self-care, lack of communication, poor quality and safety, and increased medical errors (Rosa et al., 2020). The estimate of burnout within the United States ranges from 35% to 45%, as the pandemic has exacerbated poor work environments (Rosa et al., 2020).
Investment in rapid and intelligent nursing is needed at policy and leadership levels to ensure strategic workforce optimization in all specialties and levels (Rosa et al., 2020). The level of moral distress from emotional and spiritual exhaustion is the anguish that arises from knowing what needs to be done, yet unable to act on it due to constraints that imperil clinicians’ integrity and well-being.
Theory Application
The clinical setting practice problem of nursing burnout is applied to any clinical setting as nursing is exponentially exposed to the public. These are some nursing strategies: value clinicians, communicate best practices, monitor, and promote clinician well-being, provide a supportive and blame-free work culture, enable cooperation and collaboration, and provide a central access point for Covid-19 information and updates.
References
Gray, J. R., Grove, S. K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Saunders Elsevier
Rosa, W. E., Schlak, A. E., & Rushton, C. H. (2020). A blueprint for leadership during COVID-19. Nursing Management, 8, 28. https://doi-org.ezp.waldenulibrary.org/10.1097/01.NUMA.0000688940.29231.6f
Weld, K., Padden, D., Ramsey, G., & Garmon Bibb, S. C. (2008). A framework for guiding health literacy research in populations with universal access to healthcare. Advances in Nursing Science, 31(4), 308-318.
EXAMPLE REPLY POST
The ethical challenges health care is faced with today have various laws, rules, regulations, laws, and ethical standards (Haahr et al., 2020). One of the major issues involves confidentiality, informed consent, and patient relationships, which is concerning in many health care organizations. Sabone et al. (2020) contended what is legal today might not be considered ethical, as the ever-present threat of being sued for negligence and malpractice is always at the forefront. There are still unresolved issues around when to get a minor’s parents involved about pregnancy. As we know, violating the patient’s confidentiality can hurt the patient and have legal and ethical consequences for the health care worker. As nurses, it is essential that we integrate ethical problem-solving and decision-making into our daily routine practice habits.
References
Haahr, A., Norlyk, A., Martinsen, B., & Dreyer, P. (2020). Nurses experiences of ethical dilemmas: A review. Nursing Ethics, 27, 258-272. https://doi.org/10.1177/096973 3019832941
Sabone, M., Mazonde, P., Cainelli, F., Maitshoko, M., Joseph, R., Shayo, J., Morris, B., Muecke, M., Wall, B. M., Hoke, L., Peng, L., Mooney-Doyle, K., & Ulrich, C. M. (2020). Everyday ethical challenges of nurse-physician collaboration. Nursing Ethics, 27, 206-220. https://doi.org/10.1177/0969733019840753
 
ANOTHER REPLY SAMPLE
To review a research framework model allows the depiction of relationships and presents the intention of the study and what is tested (Gray, Grove, & Sutherland, 2017). Research questions and hypotheses shine light upon the theoretical framework of research. There can be theoretical framework to show possible relations, uncertain theories, or a philosophical viewpoint (Gray, Grove, & Sutherland, 2017, p.138). You brought forward new insights gained from Theoretical Domain framework with the use of the 33 behavior change theories. These allow interventions to be presented to support behavior changes (Smith et al., 2019). A unique visual approach to allow the portrayal of those relationships and interventions between the concepts for theoretical framework is the use of concept maps. This article is set up for a superb visual to allow further explanation of the Theoretical Domain framework, particularly with this involving long-term care.
References
Gray, J.R., Grove, S.K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research:
Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Saunders Elsevier
Smith, J.D., Corace, K.M., MacDonald, T.K., Fabrigar, L.R., Saedi, A., Chaplin, A., … & Garber, G.E. (2019).
Application of the Theoretical Domains Framework to identify factors that influence hand hygiene compliance in long-term care. Journal of Hospital Infection, 1010(4), 393-398.
 

 
Essay: Write a 800-1600 word essay addressing each of the following questions. Be sure to completely answer all the questions. Separate each section in your paper with a clear heading that allows your professor to know which question you are addressing in that section of your paper. Support your ideas with at least three (3) citations in your essay. Make sure to reference the citations using the APA writing style for the essay. The cover page and reference page do not count towards the minimum word amount.
Provide an example of classical conditioning, of operant conditioning, and of habituation/recovery in young infants. Why is each type of learning useful?
Using examples, explain why intermodal perception is vital for infants’ developing understanding of their physical and social worlds.
Cite evidence that motor development is a joint product of biological, psychological, and environmental factors.
Using the text discussion on pages 153-157, construct an age-related list of infant and toddler cognitive attainments. Which ones are consistent with Piaget’s sensorimotor stage? Which develop earlier than Piaget anticipated?
What impact does toddlers’ more advanced play with toys have on the development of attention?
Why is the social-interactionist perspective attractive to many investigators of language development? Cite evidence that supports it.
Why do many infants show stranger anxiety in the second half of the first year? What factors can increase or decrease wariness of strangers?
How do genetic and environmental factors work together to influence temperament? Cite several examples from research.

 
1 A 45-year-old male comes to the clinic with a chief complaint
QUESTION 1 A 45-year-old male comes to the clinic with a chief complaint of epigastric abdominal pain that has persisted for 2 weeks. He describes the pain as burning, non-radiating and is worse after meals. Also, he denies nausea, vomiting, weight loss or obvious bleeding. Finally, he admits to bloating and frequent belching.
PMH-+ for osteoarthritis, seasonal allergies with frequent sinusitis infections.
Meds-Zyrtec 10 mg po daily and takes it year-round, ibuprofen 400-600 mg po prn pain
Family Hx-non contributary
Social history-recently divorced and expressed concern at how expensive it is to support 2 homes. Works as a manager at a local tire and auto company. He has 25 pack/year history of smoking, drinks 2-3 beers/day, and drinks 5-6 cups of coffee per day. He denies illicit drug use, vaping or unprotected sexual encounters.
Breath test in the office revealed + urease.
The healthcare provider suspects the client has peptic ulcer disease.
1 of 2 Questions:
What factors may have contributed to the development of PUD?
2 of 2 Questions:How do these factors contribute to the formation of peptic ulcers?
QUESTION 3 A 36-year-old morbidly obese female comes to the office with a chief complaint of “burning in my chest and a funny taste in my mouth”. The symptoms have been present for years but patient states she had been treating the symptoms with antacid tablets which helped until the last 4 or 5 weeks. She never saw a healthcare provider for that. She says the symptoms get worse at night when she is lying down and has had to sleep with 2 pillows. Says she has started coughing at night which has been interfering with her sleep. Also, denies palpitations, shortness of breath, or nausea.
PMH-HTN, venous stasis ulcers, irritable bowel syndrome, osteoarthritis of knees, morbid obesity (BMI 48 kg/m2)
Family history-non contributary
Medications-amlodipine 10 mg po qd, dicyclomine 20 mg po, ibuprofen 600 mg po q 6 hr prn
Social hx- 15 pack/year history of smoking, occasional alcohol use, denies vaping
The health care provider diagnoses the patient with gastroesophageal reflux disease (GERD).
Question:
The client asks the APRN what causes GERD. What is the APRN’s best response?
 
QUESTION 4 A 34-year-old construction worker presents to his Primary Care Provider (PCP) with a chief complaint of passing foul smelling dark, tarry stools. He stated the first episode occurred last week, but it was only a small amount after he had eaten a dinner of beets and beef. The episode today was accompanied by nausea, sweating, and weakness. He states he has had some mid epigastric pain for several weeks and has been taking OTC antacids. The most likely diagnosis is upper GI bleed which won’t be confirmed until further endoscopic procedures are performed.
Question:
What factors can contribute to an upper GI bleed?
 
Question 5 A 64-year-old steel worker presents to his Primary Care Provider (PCP) with a chief complaint of passing bright red blood when he had a bowel movement that morning. He stated the first episode occurred last week, but it was only a small amount after he had eaten a dinner of beets and beef. The episode today was accompanied by nausea, sweating, and weakness. He states he has had some left lower quadrant pain for several weeks but described it as “coming and going”. He says he has had a fever and abdominal cramps that have worsened this morning. The likely diagnosis is lower GI bleed secondary to diverticulitis.
Question:
What can cause diverticulitis in the lower GI tract?
 
QUESTION 6 A 48-year-old man presents to his gastroenterologist for increasing abdominal girth and increasing jaundice. He has a long history of alcoholic cirrhosis and has multiple admissions for encephalopathy and GI bleeding from esophageal varices. He has been diagnosed with portal hypertension and tells the APRN that he was told he had chronic, non-curable cirrhosis.
Question:
How does cirrhosis cause portal hypertension?
 
QUESTION 7 A 48-year-old man presents to his gastroenterologist for increasing abdominal girth and increasing jaundice. He has a long history of alcoholic cirrhosis and has multiple admissions for encephalopathy and GI bleeding from esophageal varices. He has been diagnosed with portal hypertension. The increased abdominal girth has been progressive, and he says it is getting hard to breathe. The APRN reviews his last laboratory data and notes that the total protein is 4.6 gm/dl and the albumin is 2.9 g/dl. Upon exam, he has icteric sclera, jaundice, and abdominal spider angiomas. There is a significant fluid wave when percussed. The APRN tells the patient that he has ascites.Question:Discuss how ascites develops as a result of portal hypertension.
 
QUESTION 8 A 45-year-old man with known alcoholic cirrhosis, portal hypertension, and ascites is brought to the ED by his family due to increasing confusion. The family states that he had been stumbling for several days but had not fallen. The family also noted that he had been “flapping his hands” as well. Labs in the ED reveal Hgb 9.4 g/dl, Hct 28.0 %, ammonia (NH3) level is 159 μmol/L. The APRN informs the family that the patient has developed hepatic encephalopathy (HE).
Question:
Explain how hepatic encephalopathy develops in patients with cirrhosis of the liver.
 
QUESTION 9 A 65-year-old man with a history of atrial fibrillation presents to his PCP’s office 2 months after suffering from a myocardial infarction.  He declined anticoagulation due to fear he would bleed to death. Has had sudden-onset, moderately severe diffuse abdominal pain that began 18 . Has been vomiting, and he has had several episodes of diarrhea, the last of which was bloody. He has a fever of 100.9 ˚ F. CBC reveals WBC of 15,000/mm3.
Question:
What is the most likely mechanism behind his current symptoms?
 
QUESTION 10 A 46-year-old Caucasian female presents to the PCP’s office with a chief complaint of severe, intermittent right upper quadrant pain for the last 3 days. The pain is described as sharp and has occurred after eating french fries and cheeseburgers and radiates to her right shoulder. She has had a few episodes of vomiting “green stuff”. States had fever and chills last night which precipitated her trip to the office. She also had some dark orange urine, but she thought she was dehydrated.
Physical exam: slightly obese female with icteric sclera as well as generalized jaundice. Temp 101˚F, pulse 108, respirations 18. Abdominal exam revealed rounded abdomen with slightly hypoactive bowel sounds. + rebound tenderness on palpation of right upper quadrant. No tenderness or rebound in epigastrium or other quadrants. Labs demonstrate elevated WBC, elevated serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. Serum bilirubin (indirect) 2.5 mg/dl. Abdominal ultrasound demonstrated enlarged gall bladder, dilated common bile duct and multiple stones in the bile duct. The APRN diagnoses the patient with acute cholecystitis and refers her to the ED for further treatment.
Question 1 of 2:
Describe how gallstones are formed and why they caused the symptoms that the patient presented with.
 
QUESTION 11 A 46-year-old Caucasian female presents to the PCP’s office with a chief complaint of severe, intermittent right upper quadrant pain for the last 3 days. The pain is described as sharp and has occurred after eating french fries and cheeseburgers and radiates to her right shoulder. She has had a few episodes of vomiting “green stuff”. States had fever and chills last night which precipitated her trip to the office. She also had some dark orange urine, but she thought she was dehydrated.
Physical exam: slightly obese female with icteric sclera as well as generalized jaundice. Temp 101˚F, pulse 108, respirations 18. Abdominal exam revealed rounded abdomen with slightly hypoactive bowel sounds. + rebound tenderness on palpation of right upper quadrant. No tenderness or rebound in epigastrium or other quadrants. Labs demonstrate elevated WBC, elevated serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. Serum bilirubin (indirect) 2.5 mg/dl. Abdominal ultrasound demonstrated enlarged gall bladder, dilated common bile duct and multiple stones in the bile duct. The APRN diagnoses the patient with acute cholecystitis and refers her to the ED for further treatment.
Question 2 of 2:
Explain how the patient became jaundiced.
 
QUESTION 12 Ruth is a 49-year-old office worker who presents to the clinic with a chief complaint of abdominal pain x 2 days. The pain has significantly increased over the past 6 hours and is now accompanied by nausea and vomiting. The pain is described as “sharp and boring” in mid epigastrum and radiates to the back. Ruth admits to a long history of alcohol use, and often drinks up to a fifth of vodka every day.
Physical Exam:
Temp 102.2F, BP 90/60, respirations 22. Pulse Oximetry 92% on room air.
General: thin, pale white female in obvious pain and leaning forward. Moving around on exam table and unable to sit quietly.
CV-tachycardic. RRR without gallops, rubs, clicks or murmurs
Resp-decreased breath sounds in both bases with poor inspiratory effort
Abd- epigastric guarding with tenderness. No rebound tenderness. Negative Cullen’s and + Turner’s signs observed. Hypoactive bowel sounds x 2 upper quadrants, and no bowel sounds heard in both lower quadrants.
The APRN makes a tentative diagnosis of acute pancreatitis based on history and physical exam and has the patient transferred to the ER where laboratory and radiographic exams reveal acute pancreatitis.
Question:
Explain how pancreatitis develops and the role alcohol played in this patient’s case.
 
QUESTION 13 A 23-year-old bisexual man with a history of intravenous drug abuse presents to the clinic with a chief complaint of fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, and dark urine. He says the symptoms started about a month ago and have gotten steadily worse. He admits to reusing needles and had unprotected sexual relations with a man “a couple months ago”.
PMH-noncontributory.
Social/family history-works occasionally as a night clerk in a hotel. Parents without illnesses. Admits to bisexual sexual relations and intravenous heroin use. He has refused drug rehabilitation. 3 year/pack history of tobacco but denies vaping.
Physical exam unremarkable except for palpable liver edge 2 fingerbreadths below costal margin. No ascites or jaundice appreciated.
The APRN suspects the patient has Hepatitis B given the strong history of risk factors. She orders a hepatitis panel which was positive for acute Hepatitis B.
Question:
What are the important hepatitis markers that indicated the patient had acute hepatitis B?
 
QUESTION 14 Hannah is a 19-year-old college sophomore who came to Student Health with a chief complaint of lower abdominal pain. She says the pain has been present for 2 months and she has had multiple episodes of diarrhea alternating with constipation, and anorexia. She says she has lost about 10 pounds in these 2 months without dieting. The abdominal pain has gotten worse in the last 2 hours, but she thought she had “the GI bug” like other students at her Synagogue had.
Physical exam-noncontributory except for the abdomen which was lightly distended with no visible masses. Normoactive BS x 4. Diffuse tenderness throughout but increased pain on deep palpation LUQ & LLQ. Slight guarding but no rebound tenderness or rigidity.
Rectal-tight anal sphincter and patient grimacing in pain during exam. Slightly + guaiac stool.
Based on her history and current symptoms, the APN arranges for a consult with a gastroenterologist who diagnoses Hannah with ulcerative colitis (UC).
Question:
How does ulcerative colitis develop in a susceptible person?
 
QUESTION 15 A 64-year-old woman with long standing coronary artery disease presents to the clinic with lower extremity swelling, abdominal distension, and shortness of breath. Patient states she has a 30-pound weight gain in 6 weeks and is now requiring 3 pillows to sleep.
On physical exam the patient is a well-developed, well-nourished female exhibiting signs of respiratory distress with use of accessory muscles. Blood pressure 150/80, pulse 105, respirations 28 and labored. Body weight 89 kg. HEENT was unremarkable. Cardiac exam had an S1, S2 and S3 without S4 or murmur. Respiratory exam was positive for bilateral rales 1/2 up both lung fields. Abdomen was enlarged with a positive fluid wave. Lower extremities were remarkable for 3+ pitting edema.
Laboratory data was significant for an increase in K+ from 3.4 mmol/l to 6.1 mmol/l in 2 weeks, BUN increased from 18 mg/dl to 104 mg/dl, and creatinine increased from 0.8 mg/dl to 6.9 mg/dl.
CXR revealed congestive heart failure. The APRN calls the cardiologist on call who admits the patient to the hospital and orders a nephrology consult.
She was diagnosed with exacerbation of congestive heart failure (CHF) and acute kidney injury (AKI).
Question:
What type of acute kidney injury does the patient have and what factors contributed to this diagnosis?
 
QUESTION 16 The APRN is giving a pathophysiology lecture to APRN students on renal blood flow, related hormones, and glomerular filtration rate.
Question: What would be the most important concept of glomerular filtration rate that the APRN should address?
 
QUESTION 17 The APRN is giving a pathophysiology lecture to APRN students on renal blood flow, glomerular filtration rate, autoregulation, and related hormone factors regulating renal blood flow
Question:
What would be the most important concept of autoregulation that the APRN should address?
 
QUESTION 18 The APRN is giving a pathophysiology lecture to APRN students on renal blood flow, glomerular filtration rate, autoregulation, and also related hormone factors regulating renal blood flow
Question:
What would be the most important concept of hormonal regulation that the APRN should address?
 
QUESTION 19 A 28-year-old female comes to the clinic with a chief complaint of right flank pain, urinary frequency, and foul-smelling urine. The symptoms have been present for 3 days but this morning, the patient states she had a fever of 101 F and thought she should get it checked out. Physical exam noncontributory with the exception of right costovertebral angle (CVA) tenderness upon percussion. Urine dipstick shows + blood, + bacteria and + white blood cells. Renal ultrasound reveals right staghorn renal calculus and the patient was diagnosed with acute pyelonephritis.
Question:
How does a renal calculi calculus contribute to acute pyelonephritis?
 
QUESTION 20 Mr. Kent is a 45-year-old African American male with a history of Type 2 diabetes, hypertension, and hyperlipidemia. His renal function has slowly decreased over the past 4 years and his nephrologist has told him that his GFR has decreased to 15cc ml/min and will soon need renal dialysis for chronic renal failure.
Question:
How does chronic renal failure develop?