Identify the educational preparation and role(s) of the clinical nurse leader (CNL) designation. Give an example of how the CNL influences direct patient care whether in a hospital or out in the community.

 

Clinical nurse leader (CNL) was proposed American Association of Colleges of Nursing, an effort to improve patient safety and quality of care (Graduate Nursing Edu.org). CNL is a generalist clinician who have education at master’s degree level or higher (Graduate Nursing Edu.org), upon graduation must sit for Clinical Nurse Leader Certification Examination by the Commission on Nurse Certification (University of Pittsburgh). A CNL has an advanced knowledge, not just in one area or discipline, but on general medicine, which is helpful for coordinating the care provided by the interdisciplinary teams.

CNL has roles different from other advanced practice clinicians, they are responsible for designing patient care, implementing, and evaluating the care provided to the patients, making sure that the patients receive the right care, while coordinating, delegating, and supervising the care provided by other health care teams clinically.

CNL can influence patient care by the use evidence-based practice and the latest innovated technology to improve patients’ care, they work with physicians, pharmacists, nurse practitioners and other health care teams to provide the most effective medical care (Graduate Nursing Edu.org). It is important to know that CNL serve as mentors to nursing staff, oversee the environment to ensure it is safe for the patients.

CNL can act like a patient’s advocate; they serve as a middle person between the patients and they physicians or healthcare providers. For example, a patient in the community who is not sure what and where to go for help, a CNL would use his/her expertise to inform or teach the patients and family members, the disease condition, and its management, and refer them to the appropriate places for best care.

 

References

Graduate Nursing Edu.org. (2017) Retrieved on October 2nd. From https://www.graduatenursingedu.org/clinical-nurse-leader/

University of Pittsburgh (2017) Clinical Nurse Leader (CNL). Retrieved October 2nd from http://www.nursing.pitt.edu/degree-programs/master-science-nursing-msn/msn-program-majors/clinical-nurse-leader-cnl-onsite

 

Assessing Clients With Addictive Disorders

To prepare:

Review this week’s Learning Resources and consider the insights they provide.

Review the Levy Family video Episodes 1 through 5.

The Assignment

In a 2- to 3-page paper, address the following:

After watching Episode 1, describe:

What is Mr. Levy’s perception of the problem?

What is Mrs. Levy’s perception of the problem?

What can be some of the implications of the problem on the family as a whole?

After watching Episode 2, describe:

What did you think of Mr. Levy’s social worker’s ideas?

What were your thoughts of her supervisor’s questions about her suggested therapies and his advice to Mr. Levy’s supervisor?

After watching Episode 3, discuss the following:

What were your thoughts about the way Mr. Levy’s therapist responded to what Mr. Levy had to say?

What were your impressions of how the therapist worked with Mr. Levy? What did you think about the therapy session as a whole?

Informed by your knowledge of pathophysiology, explain the physiology of deep breathing (a common technique that we use in helping clients to manage anxiety). Explain how changing breathing mechanics can alter blood chemistry.

Describe the therapeutic approach his therapist selected. Would you use exposure therapy with Mr. Levy? Why or why not? What evidence exists to support the use of exposure therapy (or the therapeutic approach you would consider if you disagree with exposure therapy)?

In Episode 4, Mr. Levy tells a very difficult story about Kurt, his platoon officer.

Discuss how you would have responded to this revelation.

Describe how this information would inform your therapeutic approach. What would you say/do next?

In Episode 5, Mr. Levy’s therapist is having issues with his story.

Imagine that you were providing supervision to this therapist, how would you respond to her concerns?

Support your approach with evidence-based literature.

Question

Question 1. Xi, a fifty-four-year-old female, has a history of migraine that does not respond well to OTC migraine medication. She is asking to try Maxalt (rizatriptan) because it works well for her friend. Which of the following actions would you take for appropriate decision making?

Prescribe Maxalt, but to monitor the use, only give her four tablets with no refills.

Prescribe Maxalt and arrange to have her observed in the clinic or urgent care with the first dose.

Explain that rizatriptan is not used for postmenopausal migraines and recommend Fiorinal (aspirin and butalbital).

Prescribe sumatriptan (Imitrex) with the explanation that it is the most effective triptan.

Question 2. Chronic pain is a complex problem. Some specific strategies to deal with it include ________.

telling the patient to “let pain be your guide” to using treatment therapies

prescribing pain medication on a pro re nata (PRN) basis to keep down the amount used

scheduling return visits on a regular basis rather than waiting for poor pain control to drive the need for an appointment

All the given options

Question 3. Phil is starting treatment with febuxostat (Uloric). Education of patients starting febuxostat includes which one of the following instructions?

Gout may worsen with therapy.

Febuxostat may cause severe diarrhea.

The patients should consume a high-calcium diet.

The patients will need frequent CBC monitoring.

Question 4. The Pain Management Contract is most appropriate for:

Patients with a history of chemical dependency or possible inappropriate use of pain medications

All patients with chronic pain who will require long-term use of opiates

Patients who have a complex drug regimen

Patients who see multiple providers for pain control

Question 5. Patients whose total dose of prednisone exceed 1 gram will most likely need a second prescription for _________.

metformin, a biguanide to prevent diabetes

omeprazole, a proton pump inhibitor to prevent peptic ulcer disease

naproxen, an NSAID to treat joint pain

furosemide, a diuretic to treat fluid retention

Question 6. Sallie has been taking 10 mg of prednisone per day for the past six months. She should be assessed for ________.

gout

iron deficiency anemia

osteoporosis

renal dysfunction

Question 7. All NSAIDs have an FDA black box warning regarding __________.

potential for causing life-threatening GI bleeds

increased risk of developing systemic arthritis with prolonged use

risk of life-threatening rashes, including Stevens-Johnson

potential for transient changes in serum glucose

Question 8. Which of the following statements is true about age and pain?

Use of drugs that depend heavily on the renal system for excretion may require dosage adjustments in very young children.

Among the NSAIDs, indomethacin is the preferred drug because of lower adverse effects profiles than other NSAIDs.

Older adults who have dementia probably do not experience much pain due to loss of pain receptors in the brain.

Acetaminophen is especially useful in both children and adults because it has no effect on platelets and has fewer adverse effects than NSAIDs.

Question 9. Kirk sprained his ankle and is asking for pain medication for his mild-to-moderate pain. The appropriate first-line medication would be __________.

ibuprofen (Advil)

acetaminophen with hydrocodone (Vicodin)

oxycodone (OxyContin)

oral morphine (Roxanol)

Question 10. Patients who are on or who will be starting chronic corticosteroid therapy need monitoring of __________.

serum glucose

stool culture

folate levels

vitamin B12

Question 11. Jamie has fractured his ankle and has received a prescription for acetaminophen and hydrocodone (Vicodin). Education when prescribing Vicodin includes which one of the following instructions?

It is OK to double the dose of Vicodin if the pain is severe.

Vicodin is not habit forming.

He should not take any other acetaminophen-containing medications.

Vicodin may cause diarrhea; therefore, he should increase his fluid intake.

Question 12. Patients prescribed aspirin therapy require education regarding the signs of aspirin toxicity. An early sign of aspirin toxicity is _____.

black, tarry stools

vomiting

tremors

tinnitus

Question 13. Henry is eighty-two years old and takes two aspirin every morning to treat the arthritis pain in his back. He states that the aspirin helps him to “get going” each day. Lately, he has had some heartburn from the aspirin. After ruling out an acute GI bleed, what would be an appropriate course of treatment for Henry?

Add an H2 blocker such as ranitidine to his therapy.

Discontinue the aspirin and switch him to Vicodin for the pain.

Decrease the aspirin dose to one tablet daily.

Have Henry take an antacid fifteen minutes before taking the aspirin each day.

Question 14. Patients with RA who are on chronic low-dose prednisone will need co-treatment with which medications to prevent further adverse effects?

A bisphosphonate

Calcium supplementation

Vitamin D

All of the above

Question 15. One of the main drug classes used to treat acute pain is NSAIDs. They are used due to which of the following reasons?

They have less risk for liver damage than acetaminophen.

Inflammation is a common cause of acute pain.

They have minimal GI irritation.

Regulation of blood flow to the kidney is not affected by these drugs.

Question 16. Chemical dependency assessment is integral to the initial assessment of chronic pain. Which of the following raises a “red flag” about potential chemical dependency?

Use of more than one drug to treat the pain

Multiple times when prescriptions are lost with requests to refill

Preferences for treatments that include alternative medicines

Presence of a family member who has abused drugs

Question 17. Jayla is a nine-year-old who has been diagnosed with migraines for almost two years. She is missing up to a week of school each month. Her headache diary confirms she averages four or five migraines per month. Which of the following would be appropriate?

Prescribe amitriptyline (Elavil) daily, start at a low dose and increase the dose slowly every two weeks until effective in eliminating migraines.

Encourage her mother to give her Excedrin Migraine (aspirin, acetaminophen, and caffeine) at the first sign of a headache to abort the headache.

Prescribe propranolol (Inderal) to be taken daily for at least three months.

Explain that it is rare for a nine-year-old to get migraines and that she needs an MRI to rule out a brain tumor.

Question 18. Narcotics are exogenous opiates. They act by ______.

inhibiting pain transmission in the spinal cord

attaching to receptors in the afferent neuron to inhibit the release of substance P

blocking neurotransmitters in the midbrain

increasing beta-lipoprotein excretion from the pituitary

Question 19. Pathological similarities and differences between acute pain and chronic pain include which of the following options?

Both have decreased levels of endorphins.

Chronic pain has a predominance of C-neuron stimulation.

Acute pain is most commonly associated with irritation of peripheral nerves.

Acute pain is diffuse and hard to localize.

Question 20. Different areas of the brain are involved in specific aspects of pain. The reticular and limbic systems in the brain influence ______.

the sensory aspects of pain

the discriminative aspects of pain

the motivational aspects of pain

the cognitive aspects of pain

Question

Question 1.

When blood glucose levels are difficult to control in type II diabetes, some form of insulin may be added to the treatment regimen to control blood glucose and limit complications risks. Which of the following statements are accurate based on research?

Premixed insulin analogues are better at lowering hemoglobin A1c and have less risk for hypoglycemia.

Premixed insulin analogues and the newer premixed insulins are associated with more weight gain than the oral antidiabetic agents.

Newer premixed insulins are better at lowering hemoglobin A1c and postprandial glucose levels than are long-acting insulins.

Patients who are not controlled on oral agents and have postprandial hyperglycemia can have NPH insulin added at bedtime.

Question 2. Lispro is an insulin analogue produced by recombinant deoxyribonucleic acid (DNA) technology. Which of the following statements about this form of insulin is not true?

The optimal time of preprandial injection is fifteen minutes.

The duration of action is increased when the dose is increased.

It is compatible with NPH insulin.

It has no pronounced peak.

Question 3. Unlike most type II diabetics where obesity is a major issue, older adults with low body weight have higher risks for morbidity and mortality. The most reliable indicator of poor nutritional status in older adults is:

Weight loss in previously overweight persons

Involuntary loss of 10% of body weight in less than six months

Decline in lean body mass over a twelve-month period

Increase in central versus peripheral body adiposity

Question 4. Sulfonylureas may be added to a treatment regimen for type II diabetics when lifestyle modifications and metformin are insufficient to achieve target glucose levels. Sulfonylureas have been moved to Step 2 therapy because they:

Increase endogenous insulin secretion.

Have a significant risk for hypoglycemia.

Address the insulin resistance found in type II diabetics.

Improve insulin binding to receptors.

Question 5. The drugs recommended by the American Academy of Pediatrics for use in children with diabetes (depending upon type of diabetes) are:

Metformin and insulin

Sulfonylureas and insulin glargine

Split-mixed dose insulin and GLP-1 agonists

Biguanides and insulin lispro

Question 6. Nonselective beta blockers and alcohol create serious drug interactions with insulin because they:

Increase blood glucose levels.

Produce unexplained diaphoresis.

Interfere with the ability of the body to metabolize glucose.

Mask the signs and symptoms of altered glucose levels.

Question 7. Diagnostic criteria for diabetes include:

Fasting blood glucose greater than 140 mg/dl on two occasions

Postprandial blood glucose greater than 140 mg/dl

Fasting blood glucose 100 to 125 mg/dl on two occasions

Symptoms of diabetes plus a casual blood glucose greater than 200 mg/dl

Question 8. Adam has type I diabetes and plays tennis for his university. He exhibits a knowledge deficit about his insulin and his diagnosis. He should be taught that:

He should increase his CHO intake during times of exercise.

Each brand of insulin is equal in bioavailability, so buy the least expensive.

Alcohol produces hypoglycemia and can help control his diabetes when taken in small amounts.

If he does not want to learn to give himself injections, he may substitute an oral hypoglycemic to control his diabetes.

Question 9. Both ACE inhibitors and some angiotensin-II receptor blockers have been approved in treating:

Hypertension in diabetic patients

Diabetic nephropathy

Both A and B

Neither A nor B

Question 10. Before prescribing metformin, the provider should:

Draw a serum creatinine level to assess renal function.

Try the patient on insulin.

Prescribe a thyroid preparation if the patient needs to lose weight.

All of the above options are .

Question 11. DPP-4 inhibitors (gliptins) act on the incretin system to improve glycemic control. Advantages of these drugs include:

Better reduction in glucose levels than other classes

Less weight gain than sulfonylureas

Low risk for hypoglycemia

Can be given twice daily

Question 12. Prior to prescribing metformin, the provider should:

Draw a serum creatinine to assess renal function.

Try the patient on insulin.

Tell the patient to increase iodine intake.

Have the patient stop taking any sulfonylurea to avoid dangerous drug interactions.

Question 13. Type II diabetes is a complex disorder involving:

Absence of insulin production by the beta cells

A suboptimal response of insulin-sensitive tissues especially in the liver

Increased levels of glucagon-like peptide in the post-prandial period

Too much fat uptake in the intestine

Question 14. Type I diabetes results from autoimmune destruction of the beta cells. Eighty-five to 90% of type I diabetics have:

Autoantibodies to two tyrosine phosphatases

Mutation of the hepatic transcription factor on chromosome 12

A defective glucokinase molecule due to a defective gene on chromosome 7p

Mutation of the insulin promoter factor

Question 15. GLP-1 agonists:

Directly bind to a receptor in the pancreatic beta cell.

Have been approved for monotherapy.

Speed gastric emptying to decrease appetite.

Can be given orally once daily.

Question 16.

Control targets for patients with diabetes include:

Hemoglobin A1c between 7 and 8

Fasting blood glucose levels between 100 and 120 mg/dl

Blood pressure less than 130/80 mm Hg

LDL lipids less than 130 mg/dl

Question 17. When the total daily insulin dose is split and given twice daily, which of the following rules may be followed?

Give two-thirds of the total dose in the morning and one-third in the evening.

Give 0.3 units/kg of premixed 70/30 insulin, with one-third in the morning and two-thirds in the evening.

Give 50% of an insulin glargine dose in the morning and 50% in the evening.

Give long-acting insulin in the morning and short-acting insulin at bedtime.

Question 18. All diabetic patients with hyperlipidemia should be treated with:

3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors

Fibric acid derivatives

Nicotinic acid

Colestipol

Question 19. Metformin is a primary choice of drug to treat hyperglycemia in type II diabetes because it:

Substitutes for insulin usually secreted by the pancreas

Decreases glycogenolysis by the liver

Increases the release of insulin from beta cells

Decreases peripheral glucose utilization

Question 20. Sitagliptin has been approved for:

Monotherapy in once-daily doses

Combination therapy with metformin

Both A and B

Neither A nor B