QUESTION 11. A 28-year-old woman presents to the clinic with a chief complaint of hirsutism and irregular menses. She describes irregular and infrequent menses (five or six per year) since menarche at 12 years of age. She began to develop dark, coarse facial hair when she was 14 years of age, but her parents did not seek treatment or medical opinion at that time. The symptoms worsened after she gained weight in college. She got married 3 years ago and has been trying to get pregnant for the last 2 years without success. Height 66 inches and weight 198. BMI 32 kg.m2. Moderate hirsutism without virilization noted.  Laboratory data reveal CMP within normal limits (WNL), CBC with manual differential (WNL), TSH 0.9 IU/L SI units (normal 0.4-4.0 IU/L SI units), a total testosterone of 65 ng/dl (normal 2.4-47 ng/dl), and glycated hemoglobin level of 6.1% (normal value ≤5.6%). Based on this information, the APRN diagnoses the patient with polycystic ovarian syndrome (PCOS) and refers her to the Women’s Health APRN for further workup and management.Question 1 of 2:What is the pathogenesis of PCOS?1 pointsQUESTION 21. A 28-year-old woman presents to the clinic with a chief complaint of hirsutism and irregular menses. She describes irregular and infrequent menses (five or six per year) since menarche at 12 years of age. She began to develop dark, coarse facial hair when she was 14 years of age, but her parents did not seek treatment or medical opinion at that time. The symptoms worsened after she gained weight in college. She got married 3 years ago and has been trying to get pregnant for the last 2 years without success. Height 66 inches and weight 198. BMI 32 kg.m2. Moderate hirsutism without virilization noted.  Laboratory data reveal CMP within normal limits (WNL), CBC with manual differential (WNL), TSH 0.9 IU/L SI units (normal 0.4-4.0 IU/L SI units), a total testosterone of 65 ng/dl (normal 2.4-47 ng/dl), and glycated hemoglobin level of 6.1% (normal value ≤5.6%). Based on this information, the APRN diagnoses the patient with polycystic ovarian syndrome (PCOS) and refers her to the Women’s Health APRN for further workup and management.Question 2 of 2:How does PCOS affect a woman’s fertility or infertility?1 pointsQUESTION 31. A 20-year-old female college student presents to the Student Health Clinic with a chief complaint of abdominal pain, foul smelling vaginal discharge, and fever and chills for the past 4 days. She denies nausea, vomiting, or difficulties with defecation. Last bowel movement this morning and was normal for her. Nothing has helped with the pain despite taking ibuprofen 200 mg orally several times a day. She describes the pain as sharp and localizes the pain to her lower abdomen. Past medical history noncontributory. GYN/Social history + for having had unprotected sex while at a fraternity party. Physical exam: thin, Ill appearing anxious looking white female who is moving around on the exam table and unable to find a comfortable position. Temperature 101.6F orally, pulse 120, respirations 22 and regular. Review of systems negative except for chief complaint. Focused assessment of abdomen demonstrated moderate pain to palpation left and right lower quadrants. Upper quadrants soft and non-tender. Bowel sounds diminished in bilateral lower quadrants. Pelvic exam demonstrated + adnexal tenderness, + cervical motion tenderness and copious amounts of greenish thick secretions. The APRN diagnoses the patient as having pelvic inflammatory disease (PID).Question:What is the pathophysiology of PID?1 pointsQUESTION 41. A 27-year-old male comes to the clinic with a chief complaint of a “sore on my penis” that has been there for 3 days. He says it burns and leaked a little fluid. He denies any other symptoms. Past medical history noncontributory. Social history: works as a bartender and he states he often “hooks up” with some of the patrons, both male and female after work. He does not always use condoms. Physical exam within normal limits except for a lesion on the lateral side of the penis adjacent to the glans. The area is indurated with a small round raised lesion. The APRN orders laboratory tests, but feels the patient has syphilis.Question:Describe the 4 stages of syphilis.1 pointsQUESTION 51. A 19-year-old female presents to the clinic with a chief complaint of “fluid filled bumps” and intense pruritis of her vulva. She states these symptoms have been present for about 10 days, but she thought she had a yeast infection. She self-medicated with over the counter (OTC) metronidazole (Flagyl™) intravaginally but the symptoms got worse. No other complaints except for fatigue out of proportion to her activity level. Past medical history noncontributory. Social history: sexually active with several men and did forget to use a condom during one sexual encounter. Physical exam negative except for pelvic exam which revealed multiple fluid filled (vesicular) lesions on the vulva and introitus. Positive lymph nodes in inguinal areas. The APRN diagnoses the patient with herpes simplex virus-type 2 known as genital herpes.Question:What is the pathophysiology of HSV-2?1 pointsQUESTION 61. A 27-year-old male presents to the clinic with a chief complaint of a gradual onset of scrotal pain and swelling of the left testicle that started 2 days ago.  The pain has gotten progressively worse over the last 12 hours and he now complains of left flank pain. He complains of dysuria, frequency, and urgency with urination. He states his urine smells funny. He denies nausea, vomiting, but admits to urethral discharge just prior to the start of his severe symptoms. He denies any recent heavy lifting or straining for bowel movements. He says the only thing that makes the pain better is if he sits in his recliner and elevates his scrotum on a small pillow. Past medical history negative. Social history + for sexual activity only with his wife of 3 years. Physical exam reveals red, swollen left testicle that is very tender to touch. There is positive left inguinal adenopathy. Clean catch urinalysis in the clinic + for 3+ bacteria. The APRN diagnoses the patient with epididymitis.Question:Discuss how bacteria in the urine causes epididymitis.1 pointsQUESTION 71. A 42-year-old male presents to the clinic with a chief complaint of fever, chills, malaise, arthralgias, dysuria, urinary frequency, low back pain, perineal, and suprapubic pain. He says he feels like he can’t fully empty his bladder when he voids. He states these symptoms came on suddenly about 12 hours ago and have gotten worse. He noticed some blood in his urine the last time he voided. He tried to have a bowel movement several hours ago but could not empty his bowel due to pain. Past medical and social history noncontributory. Physical exam reveals an ill appearing male. Temperature 101.8 F, pulse 122, respirations 20, BP 108/68. Exam unremarkable apart from left costovertebral angle (CVA) tenderness. Rectal exam difficult due to enlarged and extremely painful prostate.  Complete blood count revealed an elevated white blood cell count, elevated C-reactive protein and elevated sedimentation rate. Urine dip in the clinic + for 2+ bacteria.Question:Explain the differences between acute bacterial prostatitis and nonbacterial prostatitis.Path: pWords:01 pointsQUESTION 81. A 32-year-old woman presents to the clinic with a chief complaint of pelvic pain, excessive menstrual bleeding, dyspareunia, and inability to become pregnant after 18 months of unprotected sex with her husband. She states she was told she had endometrioses after a high school physical exam, but no doctor or nurse practitioner ever mentioned it again, so she thought it had gone away. She has no other complaints and says she wants to have a family. Past medical history noncontributory except for possible endometriosis as a teenager. Social history negative for tobacco, drugs or alcohol. The physical exam is negative except for the pelvic exam which demonstrated pain on light and deep palpation of the uterus. The APRN believes that the patient does have endometriosis and orders appropriate laboratory and radiological tests. The diagnostics come back highly suggestive of endometriosis.Question:Explain how endometriosis may affect female fertility.1 pointsQUESTION 91. An APRN working in an anticoagulation clinic has been asked by the local college to present a lecture on platelets and their role in blood clotting to the graduate pathophysiology nursing students.Question:What key concepts should the APRN include in the presentation?1 pointsQUESTION 101. A 36-year-old woman presents to the clinic with complaints of dyspnea on exertion, fatigue, leg cramps on climbing stairs, craving ice to suck or chew and cold intolerance. The symptoms have come on gradually over the past 4 months. The only thing that make the symptoms better is for her to sit or lie down and stop the activity. She denies bruising or bleeding and states this is the first time this has happened. Past medical history noncontributory except for a new diagnosis of benign uterine fibroids 6 months ago after experiencing heavy menstrual bleeding every month. Social history noncontributory and she denies alcohol, tobacco, or drug use. Physical exam: pale, thin, Caucasian female who appears older than stated age. Physical exam remarkable for a soft I/IV systolic murmur, pallor of the mucous membranes, spoon-shaped nails (koilonychia), glossy tongue, with atrophy of the lingual papillae, and fissures at the corners of the mouth. The APRN suspects the patient has iron deficient anemia (IDA) secondary to excessive blood loss from uterine fibroids. The appropriate laboratory tests confirmed the diagnosis.Question:Discuss iron deficiency anemia and how the patient’s menstrual bleeding contributed to the diagnosis.1 pointsQUESTION 111. A 67-year-old woman presents to the clinic with complaints of weakness, fatigue, paresthesias of the feet and fingers, difficulty walking, loss of appetite, and a sore tongue. These symptoms have been present for several months but the patient thought they were due to her recent retirement and geographic move from the Midwest to New England. The symptoms have gotten worse over the past few weeks and she has noticed that she is much more forgetful. This is of great concern as she worries she might have the beginning stages of Alzheimer’s Disease. Past medical history significant for Hashimoto thyroiditis that she developed in her early 20s. The rest of PMH and social history non- contributory. Physical exam reveals an average sized female whose skin has a sallow appearance. BP 128/74, Pulse 120, respirations 18 and temperature 99.0F orally. Examination of the head and neck reveals a smooth and beefy red tongue. Abdominal exam negative for hepatomegaly or splenomegaly.The APRN recognizes these symptoms and physical exam indicate the patient has pernicious anemia. After appropriate laboratory data received, the definitive diagnosis of pernicious anemia was made.Question 1 of 2:How does pernicious anemia develop?1 pointsQUESTION 121. A 67-year-old woman presents to the clinic with complaints of weakness, fatigue, paresthesias of the feet and fingers, difficulty walking, loss of appetite, and a sore tongue. These symptoms have been present for several months but the patient thought they were due to her recent retirement and geographic move from the Midwest to New England. The symptoms have gotten worse over the past few weeks and she has noticed that she is much more forgetful. This is of great concern as she worries she might have the beginning stages of Alzheimer’s Disease. Past medical history significant for Hashimoto thyroiditis that she developed in her early 20s. The rest of PMH and social history non- contributory. Physical exam reveals an average sized female whose skin has a sallow appearance. BP 128/74, Pulse 120, respirations 18 and temperature 99.0F orally. Examination of the head and neck reveals a smooth and beefy red tongue. Abdominal exam negative for hepatomegaly or splenomegaly.The APRN recognizes these symptoms and physical exam indicate the patient has pernicious anemia. After appropriate laboratory data received, the definitive diagnosis of pernicious anemia was made.Question 2 of 2:How does pernicious anemia cause the neurological manifestations that are often seen in patients with PA?1 pointsQUESTION 131. A 49-year-old man with a 22-year history of severe rheumatoid arthritis (RA) presents to clinic for his preadmission testing (PAT) and medical clearance for a planned right total hip arthroplasty. The patient had been severely limited in ambulation due to the RA. Current medications include prednisone 20 mg po qd and methotrexate 7.5 mg Thursdays, 5mg Fridays, and 7.5 mg Saturdays.  The patient had a complete blood count (CBC) with manual differentiation and red blood cell indices, complete metabolic panel (CMP) and coagulation studies (prothrombin time [PT], international normalized ratio [INR] and activated partial thromboplastin time [aPTT]). All the laboratory studies come back within normal limits except for the red blood cell indices. The hemoglobin and hematocrit were low along with mean corpuscle volume, plasma iron and total iron binding capacity, and transferrin also being low. There was a normal reticulocyte count, normal ferritin, serum B12, folate and bilirubin.The APRN in the PAT clinic recognizes that the patient has anemia of chronic disease (ACD).Question 1 of 2:What is ACD and how does it develop?1 pointsQUESTION 141. A 49-year-old man with a 22-year history of severe rheumatoid arthritis (RA) presents to clinic for his preadmission testing (PAT) and medical clearance for a planned right total hip arthroplasty. The patient had been severely limited in ambulation due to the RA. Current medications include prednisone 20 mg po qd and methotrexate 7.5 mg Thursdays, 5mg Fridays, and 7.5 mg Saturdays.  The patient had a complete blood count (CBC) with manual differentiation and red blood cell indices, complete metabolic panel (CMP) and coagulation studies (prothrombin time [PT], international normalized ratio [INR] and activated partial thromboplastin time [aPTT]). All the laboratory studies come back within normal limits except for the red blood cell indices. The hemoglobin and hematocrit were low along with mean corpuscle volume, plasma iron and total iron binding capacity, and transferrin also being low. There was a normal reticulocyte count, normal ferritin, serum B12, folate and bilirubin.The APRN in the PAT clinic recognizes that the patient has anemia of chronic disease (ACD).Question 2 of 2:Why do patients with chronic kidney disease (CKD) develop ACD?1 pointsQUESTION 151. A 14-year-old female is brought to the Urgent Care by her mother who states that the girl has had an abnormal number of bruises and “funny looking red splotches” on her legs. These bruises were first noticed about 2 weeks ago and are not related to trauma. Past medical history not remarkable and she takes no medications. The mother does state the girl is recovering from a “bad case of mono” and was on bedrest at home for the past 3 weeks. The girl noticed that her gums were slightly bleeding when she brushed her teeth that morning.Labs at Urgent Care demonstrated normal hemoglobin and hematocrit with normal white blood cell (WBC) differential. Platelet count of 100,000/mm3 was the only abnormal finding. The staff also noticed that the venipuncture site oozed for a few minutes after pressure was released. The doctor at Urgent Care referred the patient and her mother to the ED for a complete work up of the low platelet count including a peripheral blood smear for suspected immune thrombocytopenia purpura (ITP).Question:What is ITP and why do you think this patient has acute, rather than chronic, ITP?1 pointsQUESTION 161. A 22-year-old male is in the Surgical Intensive Care Unit (SICU) following a motor vehicle crash (MVC) where he sustained multiple life-threatening injuries including a torn aorta, ruptured spleen, and bilateral femur fractures. He has had difficulty maintaining his mean arterial pressure (MAP) and has required various vasopressors. He has a triple lumen central venous catheter (CVC) for monitoring his central venous pressure, administration of medications and blood products, as well as total parenteral nutrition. Per hospital protocol, he is receiving an unfractionated heparin 1:1000 flush after administration of each of the triple antibiotics that have been ordered to maintain patency of the lumens.  Seven days post injury, the APRN in the SICU is reviewing the patient’s morning labs and notes that his platelet count has dropped precipitously to 50,000 /mm3 from 148,000/mm3 two days ago. The APRN suspects the patient is developing heparin induced thrombocytopenia (HIT).Question 1 of 2:What is underlying pathophysiology of heparin induced thrombocytopenia?1 pointsQUESTION 171. A 22-year-old male is in the Surgical Intensive Care Unit (SICU) following a motor vehicle crash (MVC) where he sustained multiple life-threatening injuries including a torn aorta, ruptured spleen, and bilateral femur fractures. He has had difficulty maintaining his mean arterial pressure (MAP) and has required various vasopressors. He has a triple lumen central venous catheter (CVC) for monitoring his central venous pressure, administration of medications and blood products, as well as total parenteral nutrition. Per hospital protocol, he is receiving an unfractionated heparin 1:1000 flush after administration of each of the triple antibiotics that have been ordered to maintain patency of the lumens.  Seven days post injury, the APRN in the SICU is reviewing the patient’s morning labs and notes that his platelet count has dropped precipitously to 50,000 /mm3 from 148,000/mm3 two days ago. The APRN suspects the patient is developing heparin induced thrombocytopenia (HIT).Question 2 of 2:The APRN assesses the patient and notes there is a decreased right posterior tibial pulse with cyanosis of the entire foot. The APRN recognizes this probably represents arterial thrombus formation. How does someone who is receiving heparin develop arterial and venous thrombosis?1 pointsQUESTION 181. A 33-year-old female is brought to Urgent Care by her husband who states his wife has gotten suddenly confused and complains of a severe headache. He also noticed large bruises on her legs which were not there yesterday. Only significant past medical history is that the patient developed herpes zoster 2 weeks ago and was given acyclovir for treatment. Physical exam revealed well developed female who is only oriented to person. Large areas of ecchymosis noted on both arms and legs. Stat CBC revealed a platelet count of 18,000/mm3, hemoglobin of 8 g/dl and hematocrit of 24%. The patient was immediately transported to the Emergency Room by Emergency Medical Services (EMS) where further work up demonstrated idiopathic thrombotic thrombocytopenic purpura (TTP).Question:What is the pathophysiology of TTP?1 pointsQUESTION 191. A 64-year man is recovering from a transurethral resection of the prostate for treatment of benign prostate hyperplasia. The patient is receiving intravenous antibiotics for the urinary tract infection that was found on the preoperative urine culture and sensitivity (C & S). The post-operative course has been smooth and the APRN is removing the 3-way Foley catheter when there is a sudden release of bright red blood with many blood clots in the Foley bag. The patient becomes hypotensive, tachycardic and the APRN notes new ecchymoses on the patient’s arms and legs. The patient was immediately transferred to the surgical intensive care unit (SICU) and a stat hematology consult was conducted. Stat CBC, d-dimer, peripheral blood smear, partial thromboplastin time, Prothrombin time/international normalization ratio (INR), and fibrinogen labs were drawn. Results were:CBC with markedly decreased platelet count, peripheral blood smear showed decreased number of platelets and presence of large platelets and fragmented red cells (schistocytes), prothrombin time prolonged as was the partial thromboplastin time. The d-dimer was markedly elevated, and fibrinogen level was low. The diagnosis of disseminated intravascular coagulation (DIC) was made based on clinical picture and laboratory data.Question 1 of 2:What is DIC and how does it develop?1 pointsQUESTION 201. A 64-year man is recovering from a transurethral resection of the prostate for treatment of benign prostate hyperplasia. The patient is receiving intravenous antibiotics for the urinary tract infection that was found on the preoperative urine culture and sensitivity (C & S). The post-operative course has been smooth and the APRN is removing the 3-way Foley catheter when there is a sudden release of bright red blood with many blood clots in the Foley bag. The patient becomes hypotensive, tachycardic and the APRN notes new ecchymoses on the patient’s arms and legs. The patient was immediately transferred to the surgical intensive care unit (SICU) and a stat hematology consult was conducted. Stat CBC, d-dimer, peripheral blood smear, partial thromboplastin time, Prothrombin time/international normalization ratio (INR), and fibrinogen labs were drawn. Results were:CBC with markedly decreased platelet count, peripheral blood smear showed decreased number of platelets and presence of large platelets and fragmented red cells (schistocytes), prothrombin time prolonged as was the partial thromboplastin time. The d-dimer was markedly elevated, and fibrinogen level was low. The diagnosis of disseminated intravascular coagulation (DIC) was made based on clinical picture and laboratory data.Question 2 of 2:What factors contribute to the development of DIC?

Case Study: Urinary Tract InfectionYou are working in an extended care facility when M.Z.’s daughter brings her mother in for a week’s stay while she goes on a planned vacation. M.Z. is an 89-year-old widow with a 4-day history of non- localized abdominal pain, incontinence, new-onset mental confusion, and loose stools. Her most current vital signs are 118/60, 88, 18, 98.4° F (37.4° C). The medical director ordered a post void catheterization, which yielded 100mL of cloudy urine that had a strong odor, and several lab tests on admission. Urine culture and sensitivity results are pending; the other results are shown in the chart.Chart View Laboratory Test Results:Complete metabolic panel: Within normal limits except for the following results:BUN 25mg/dL Sodium 131mEq/LPotassium 3.2mEq/LWhite blood cell count 11,000/mm3Urinalysis Appearance Cloudy Odor FoulpH 6.9Protein NegativeNitrites PositiveCrystals NegativeWBCs 6 per low-power fieldRBCs 3What condition do the lab reports point toward?Which assessment findings are typical of an older adult with the condition in Question 1?Considering her history and laboratory results, what other condition is a possibility?4.The medical director makes rounds and writes orders to start an IV of D5 ½NS at 75mL/hr. and insert a Foley catheter to gravity drainage. Because M.Z. is unable to take oral medications, the medical director orders ciprofloxacin (Cipro) 400mg q12h IV piggyback (IVPB). Are the type of fluid and rate appropriate for M.Z.’s age and condition? Explain.5. While the IVPB ciprofloxacin is being administered, which adverse effects might occur?6. You enter the room to start the IV infusion and insert the Foley catheter and find that the nursing assistive personnel (NAP) has taken M.Z. to the bathroom for a bowel movement. M.Z. asks you to help her, and, as you open the door, you observe her wiping herself from back to front. What do you need to do at this time?7. Because M.Z. has been having diarrhea, what special instructions should you give the NAP assigned to give basic care to M.Z.?Case Study Progress:The next day, you are the nurse assigned to M.Z.’s care. You notice that the NAP emptying the gravity drain is not wearing personal protection devices. You also observe that the drainage port of the drainage bag was contaminated during the process because the NAP allowed it to touch the floor.8. What issues need to be considered in protecting M.Z.’s safety? Describe your actions in working with the nursing assistant.9. As you assess M.Z., you notice that her catheter tubing is not secured. Why does the tubing need to be secured, and where is the correct place for the catheter tubing?10. What changes, if any, will be made to the antibiotic therapy?

Discussion: Using the Walden LibraryWhere can you find evidence to inform your thoughts and scholarly writing? Throughout your degree program, you will use research literature to explore ideas, guide your thinking, and gain new insights. As you search the research literature, it is important to use resources that are peer-reviewed and from scholarly journals. You may already have some favorite online resources and databases that you use or have found useful in the past. For this Discussion, you explore databases available through the Walden Library.To Prepare:Review the information presented in the Learning Resources for using the Walden Library, searching the databases, and  evaluating online resources.Begin searching for a peer-reviewed article that  pertains to your practice area and interests you.Post the following:Using proper APA formatting, cite the peer-reviewed article you selected that pertains to your practice area and is of particular interest to you and identify the database that you used to search for the article. Explain any difficulties you experienced while searching for this article. Would this database be useful to your colleagues? Explain why or why not. Would you recommend this database? Explain why or why not.**Use at least 3 references**

Realtors rely on detailed property appraisals—conducted using appraisal tools—to assign market values to houses and other properties. These values are then presented to buyers and sellers to set prices and initiate offers.Research appraisal is not that different. The critical appraisal process utilizes formal appraisal tools to assess the results of research to determine value to the context at hand. Evidence-based practitioners often present these findings to make the case for specific courses of action.In this Assignment, you will use an appraisal tool to conduct a critical appraisal of published research. You will then present the results of your efforts.To Prepare:Reflect on the four peer-reviewed articles you selected in Module 2 and the four systematic reviews (or other filtered high- level evidence) you selected in Module 3.Reflect on the four peer-reviewed articles you selected in Module 2 and analyzed in Module 3.Review and download the Critical Appraisal Tool Worksheet Template provided in the Resources.The Assignment (Evidence-Based Project)Part 3A: Critical Appraisal of ResearchConduct a critical appraisal of the four peer-reviewed articles you selected by completing the Evaluation Table within the Critical Appraisal Tool Worksheet Template. Choose a total of four peer- reviewed articles that you selected related to your clinical topic of interest in Module 2 and Module 3.Note: You can choose any combination of articles from Modules 2 and 3 for your Critical Appraisal. For example, you may choose two unfiltered research articles from Module 2 and two filtered research articles (systematic reviews) from Module 3 or one article from Module 2 and three articles from Module 3. You can choose any combination of articles from the prior Module Assignments as long as both modules and types of studies are represented.Part 3B: Critical Appraisal of ResearchBased on your appraisal, in a 1-2-page critical appraisal, suggest a best practice that emerges from the research you reviewed. Briefly explain the best practice, justifying your proposal with APA citations of the research.By Day 7 of Week 7Submit Part 3A and 3B of your Evidence-Based Project

MODULE 2.3 – DiscussionInstructions:Click and read the Case Study below and post answers.Chapter 16 – Case StudyAnswers must:Be 100 words or moreUse the stand English grammar and spellingReferences are cited (if necessary)