Case Study: Physiological Adaptation – NCLEX-RN®

00:00 Hi. Welcome to our case study. I'm Professor Lawes and I'm going to teach you the key strategies on how you can break this down and be successful on these types of questions.

00:12 So, let's get started. Our first case study is from the NCLEX category of Physiological Adaptation.

00:19 Now, let me just tell you, at the beginning these are beautiful graphics that we drew to help you, but you won't see these on the NCLEX.

00:27 These are just to help you kind of get started and to get your brain engaged in picturing the scene because that's one of the things I recommend to all students.

00:37 Make sure you picture things as you're reading them, it will help focus your brain.

00:42 So let's read it. The nurse cares for a 58-year-old male who was brought into the emergency department by his son.

00:49 So, have a picture in your mind, you see what our picture is. I want you to have a picture in your mind and to make that a habit.

00:57 I promised students who slowed down on our methodical when they work through the questions get better answers. So, let's look at the nurse's notes.

01:07 The client reports heaviness and pain in his chest that comes and goes over the past 3 days.

01:13 The client states "When I was shovelling snow this morning I felt continuous chest discomfort." Okay, I read it through once, that's my strategy. Read it through once and then go back and look for things that are normal or abnormal.

01:27 So look at that first line. Client reports heaviness and pain in his chest. That's not normal.

01:35 So that gets our attention right away, heaviness and pain in his chest. Now it tells us about the frequency.

01:41 It comes and it goes and it's been lasting over the past 3 days. So we know that this is not like immediate. Right? Didn't just start happening an hour ago. This has been happening over the past 3 days.

01:54 Now, those next 3 words, "the client states." Ding, ding, ding, ding, ding. You need to really pay attention every time you see that.

02:04 And in NCLEX question, when the client is communicating something to you, it's an important focus of that question.

02:12 So, what does the client state? "When I was shovelling snow this morning, I felt continuous chest discomfort." So they're giving you more information. When you're shovelling snow, that's a lot of exertion. Right? It takes a lot of work to shovel snow.

02:29 Now the chest pain is different and that it's continuous discomfort. Before it came and went, now it is continuous.

02:37 Now, you might be asking yourself why are we spending this much time? Well, first of all it's because we're walking through this together in teaching you the skill of what you want to do.

02:47 When you practice these skills, you will be much faster, but in the beginning I want you to slow down and think the same thoughts when you see assessment information.

02:57 Is it normal or abnormal? What's the change? What's different? What is the patient communicating to me? So that you don't miss a key component when you have to answer the question.

03:08 See, in a case study, there are multiple questions that you have to answer all about this client.

03:15 If you race through these points, you could likely miss something really important and you might risk picking up wrong answers.

03:22 So, slow and steady, I promise we'll get you to the best answer. Let's look at the next bullet point.

03:30 The client is diaphoretic and reports, what, fatigue and nausea. None of those are normal.

03:37 So, they're diaphoretic, report fatigue and nausea, and that's happening right now.

03:43 The client rates his pain as an 8 on a 1-10 scale. It is not normal to have an 8 but this tells us the chest pain is pretty severe.

03:52 Now, physical examination reveals absent jugular vein distension. Is that normal? Yes, because if they had jugular vein distension, that would mean they're fluid volume overloaded.

04:05 So this piece of assessment information they're pointing us to that this patient is not currently fluid volume overloaded to the point where their jugular veins would be distended.

04:15 Now, they hear S1 and S2 heard. Is that normal? Yes. S1 and S2 that's what we would expect to hear.

04:24 There's no indication that they have a type of murmur, so we're going to look at that as normal.

04:29 Now, they have continuous telemetry shows an irregular heart rate. Well, that's not normal right in the word.

04:36 So, I have somebody who has had chest pain off and on for 3 days. Right? Now, when I see them they say it's been continuous since they were shovelling snow. They're sweaty because they're diaphoretic. They report fatigue.

04:48 They're tired and they're nauseated. None of which is normal. And their pain is 8 out of a scale of 1-10.

04:55 I know they're not fluid volume overloaded to the point where their jugular vein would be distended.

05:00 Normal heart tones, but I see an irregular rate on the monitor. Again, don't go on through this question until you have put everything into your own words.

05:12 Why? Because your brain has to do these mental gymnastics that will help focus it.

05:18 When you do the work of putting a question into your own words, I promise you you're going to increase your overall exam scores.

05:28 Let's look at the rest of his information. He is oriented to person, place, and time. That's normal. Pupils are equal, round, and reactive to light. That's normal.

05:38 Skin is pale. Hhmmm, maybe yes, maybe no, let's see what the next item is. Capillary refill of greater than 3 seconds.

05:48 That's abnormal. Right? It should be less than 3 seconds. So in that first bullet point, what stands out to me? That sluggish capillary refill.

05:57 Okay, so now I'm going to move on to the next one. The client is unable to finish a full statement due to shortness of breath. Okay, that's not normal.

06:10 If you're exercising at the appropriate rate, you should be able to have a short conversation.

06:16 This gentleman just seated, can't finish a full statement. That's how severe his shortness of breath is. So, abnormal.

06:24 So far I've got sluggish capillary refill, I've got shortness of breath. Their bowel sounds are heard in all 4 quadrants.

06:32 So that's not our problem. Right? That's going well. Peripheral pulse is 2+ bilaterally.

06:38 Normal. Right? That's within normal limits. And 1+ edema is noted to the bilateral low extremities.

06:46 Okay, that's not exactly normal, it's not normal but it might have different causes.

06:53 He has a history of diabetes, hypertension, and hyperlipidemia. Okay, those are risk factors.

07:00 We know that diabetics and hypertension and people with elevated lipids do have some particular risk factors that can lead to some problems with heart disease.

07:10 Now, the client reports, okay he quit smoking at age 54.

07:15 That's good for the last 4 years, but that's also another risk factor you want to keep in mind.

07:20 Also drinks 2-3 glasses of alcohol occasionally. That's still within normal limits. The client's body mass index is 36.6 which is above normal.

07:31 And the pulse oximetry reading is 89% on room air.

07:36 Okay, for a man of this age to have a pulse ox of 89% and you know he is short of breath, having chest pain, that is concerning.

07:46 This gentleman is 5'4" and weighs 212 pounds. Before you go on, let's summarize what should stand out to you in this. Capillary refill is slow.

07:59 So short of breath, can't finish a statement. Don't care about the bowel sounds. A little bit of edema in the bilateral lower extremities, meaning their legs.

08:09 Has a history of risk factors with diabetes, hypertension, hyperlipidemia. He did smoke up until 4 years ago.

08:17 The alcohol, I'm not really concerned about, this is moderate. His BMI is elevated.

08:22 That's another risk factor and it gives us his height 5'4" and weight of 212 pounds.

08:28 So you've got those all in your backpack. Right? As you're moving forward, you've got this picture of the patient in your mind.

08:37 Now, let's look at his vital signs on admission. Temperature. Look at that number. Is it high, low, or normal? All normal.

08:44 You don't get more normal than 98.6. Right? Heart rate 120. This is too high. This isn't an infant.

08:53 This is a 58-year-old man so a heart rate greater than 100 on your NCLEX exam is too high. Respiratory rate 24.

09:02 That's also high and we know that his heart rate is fast, his respiratory rate is fast, and his blood pressure is elevated.

09:09 In NCLEX questions, you would want 120/80 as the marker.

09:13 I know in real life, numbers can be adjusted a little bit but for your exams think of 120/80 as a normal blood pressure.

09:21 So in addition to what we just talked about, you've got normal temp, heart rate too fast, respiratory rate too fast, and blood pressure that is elevated.

09:30 It also lines up with his history that he has hypertension.

09:35 Moving through the question, you'll be able to see the medications the patient is taking at home.

09:40 You've got losartan 50 mg p.o. q.d. in the morning. q.d. means each day and he takes it in the morning.

09:49 Atorvastatin 40 mg p.o. (that means by mouth) q.d. (everyday) at bedtime. Metformin 500 mg p.o. (by mouth) b.i.d. (twice a day).

10:03 Remember with metformin, they would take it with breakfast and with dinner.

10:09 Now let's take a look at what this question would look like on your NCLEX exam.

10:14 Now first, we showed you some diagrams, we blew it up bigger so you could see things as we wanted you to think through it and walk through it.

10:22 Now we're going to show you what it looks like on the actual exam.

10:26 Now, you can see on the left side of the screen you've got the nurse's notes that we've already walked through. You've also got 2 additional tabs.

10:34 Now, I'll show you those as we move through that just to kind of reorient you to where you are.

10:38 You've got a tab for vital signs and a tab for medications. But right now, look at the nurse's notes.

10:44 That's the same information we just went through together. You just see it now in the format you'll see on the screen when you're taking your NCLEX.

10:53 So, you've got the bulleted points there. What I'd like you to do is to pause and write down some short strategies.

11:00 What are you willing to commit to doing when you're faced with this format of the question? What are the tips and strategies that we shared and worked through together when we went through the nurse's notes.

11:11 When you're done writing those down, come on back and we'll walk through the rest of the question.

11:22 Okay, welcome back. Whether you took that opportunity or not, I really want to encourage you to use these case study work throughs to develop your strategies.

11:32 Most of us want to race through these things because it's uncomfortable and we're nervous, but you're not doing yourself a service.

11:39 You want to make sure that you do the work of really identifying what the question is asking you before you race through the answers.

11:48 Now on the left hand side, there is all the information about the question. On the right side, you'll see those are the answer choices.

11:56 We're going to work through it. So, left side all the information about the patient. You see we have 3 tabs there.

12:02 When you're taking the NCLEX, you'd be able to click on each tab as many times as you want, but I really recommend going through them slowly once so you've got that all down.

12:12 And then on the right side is where you do the work and you answer the questions.

12:16 Now, see here you've got the nurse's notes, click so you can see it up there. The next tab is the vital signs that we went over.

12:23 But you'll see as the tabs are changing on the left, and these are things that we've already talked about, notice how the information on the right doesn't change.

12:33 So when you sit down to take this test, you can look at these tabs, work through the information and as you're doing that the only thing that's going to change are the tabs.

12:44 And what you see on the left hand side, the right hand side will stay the same. Alright, so you've got the format of what it looks like.

12:52 Now, let's move over to the right side and we're going to work through those answer choices, but we're going to blow it up bigger so it's easier for you to see exactly what we're talking about.

13:01 So the question is asking us to select the 4 findings that require immediate follow-up.

13:08 Okay, so what do we want to take from this? Well, how many findings? 4. Be very careful when they tell you the number that it needs to be.

13:17 You've got to hit that, not 3, not 5, it's absolutely 4. This is not a select-all-that-apply, this is a find 4 of these 8 answers that required immediate follow-up.

13:29 So essentially, you're looking at kind of prioritization. What are the top 4 things of these 8 things that you should do? So there's likely going to be some of them on there that you think should be a priority, but when you have to pick between the top 4, that's going to make the difference.

13:46 So, look at them there. We've got chest pain, vital signs, pulse characteristics, edema, body mass index, capillary refill, alcohol intake, and telemetry.

13:56 Okay, so what should we do? I recommend start on the left, work your way all the way through what you're here.

14:04 I'm looking for the top 4 things. Now, chest pain. Is this something that requires immediate follow-up. Oh, absolutely.

14:14 Chest pain requires immediate follow-up because that's an indication that they're at least having ischemia, maybe even have already infarcted something. Right? So, when a patient has chest pain, they'll put you right to that front of the line in any ER because we want to follow up and make sure that's not cardiac muscle damage.

14:33 Now, is chest pain a possible sign for other things? Oh, absolutely. It might not be a heart event. It might feel like a heart event, but it might not be.

14:43 And your job in this case being the nurse, right, as a student taking the question, is to recognize which signs do you need to jump on and immediately follow up.

14:52 Chest pain is one of those things. Next, vital signs. Well, you've got temperature, pulse, respirations, pulse ox.

15:02 Those are all part of the vital signs. This gentleman's oxygen saturation is 89% on room air.

15:09 That is too low for a normal 58-year-old male. Right? And also we noticed that respiratory rate was high.

15:17 So, this is something you'd want to follow up on. Right? So, so far I've got chest pain and the vital signs.

15:23 Yes, I do want to follow up on those. Now, can I ever change my answer? I sure can.

15:29 But for now, I would say yes to chest pain, yes to vital signs. So, Prof Lawes what do you mean "for now?" Well, when you take the NCLEX exam, you'll be given a write on wipe off board.

15:41 You can write down 1, 2, 3, 4, 5, 6, 7, 8 and you can select the answers or cross through the answers or say "you're not going to pick them on your write on, wipe off board." I recommend you do the work on your board and then put your final answer on to the screen.

15:57 That's just something the students have told me worked much more effectively for them, then changing their answers on the board because once you clicky, clicky, clicky, clicky, clicky, clicky change things on the board, you start to really doubt yourself that you know the answers.

16:09 So if I was working through this, I'd be like yup I'm going to follow up on chest pain.

16:12 Vital signs, yeah. This guy showed me his respiratory rate is really fast and his saturation is still lower than normal.

16:21 Now, pulse characteristics. Oh, that was a normal finding. I am not selecting that.

16:26 That was right on the money. What about edema? Okay, this does concern me because he really shouldn't have edema.

16:33 However, it's a mild case. 1+ is really not that big a deal. We do need to follow up on it but this question is asking me for immediate follow-up.

16:43 See there are lots of other things that could cause this 1+ edema. Maybe the medication that he is on caused it.

16:49 So, not really my top priority but it will require follow-up later, just not in immediacy.

16:57 Now, body mass index. Yeah, that's a risk factor for the patient. It's higher than normal, but it's not my immediate priority.

17:05 We could educate the patient, walk through the patient with motivational interviewing techniques.

17:09 Teach them but teaching is not going to be an in-the-moment priority for someone who is in a crisis. Right? So, teaching is important. We believe that it should be done and it should be done well, but it's not an immediate crisis for something we want to deal with as a priority.

17:27 Now, the capillary refill. That was a little slower than normal.

17:31 Now this may indicate a perfusion problem because capillary refill tells us about the blood supply to the very end of the line. Right? Fingers and toes are usually where we check that.

17:41 This capillary refill was slower than normal so this may indicate a perfusion problem and this requires follow-up.

17:49 So, I've said yes to chest pain, yes to vital signs, I'm not so worried about body mass index because that's going to be a teaching thing.

17:59 Yes to capillary refill, but still keep going through the rest of the answers.

18:05 Now, alcohol intake. A normal alcohol intake of a healthy adult male is considered 1-2 glasses per day for an adult male.

18:14 So, alcohol intake, not my top priority when you're in the ER with chest pain and you're breathing fast, your sat is low, and you're telling me to get pain of 8/10.

18:25 How much alcohol you drink is not the top of my list and this is still within normal limits.

18:32 Now, last piece. Show an irregular heart rate on telemetry. Irregular heart rate is not normal.

18:41 Whether it's caused by PVCs or atrial fib, we don't know. But it's telling us irregular heart rate, that's not normal.

18:47 Normal sinus rhythm is very regular. So we know that an irregular heart rate could also impact perfusion.

18:54 So yeah, we are going to follow up on that. So looking at our 8 options here.

19:02 So far we only checked chest pain, vital signs, capillary refill, and telemetry.

19:08 So same at this point in the question and those are the 4 that I'm selected, I do 1 more thing.

19:13 I go back and I say "Does this make sense?" From the picture in my head, is immediate follow-up required for chest pain? Yes.

19:22 For vital signs? Yes. Pulse characteristics are not more important than chest pain, vital signs, the slow refill, or the irregular heart rate.

19:31 So, I'm still okay with leaving that out. Edema, it's mild.

19:36 It's not as important as chest pain, vital signs, slow cap refill, and what we're seeing on the telemetry.

19:43 Body mass index, not normal, but not a higher priority than chest pain.

19:48 Vital signs, slow capillary refill or the irregular heart rate on telemetry.

19:55 Alcohol intake, not a problem here and it's definitely not a higher priority than the other 4 answers.

20:02 I'm going to check one more time and see it says 4 findings.

20:05 I've checked 4 findings, I did one more read through the question to make sure this all makes sense and I know it's tedious to do it that way, but you'll catch yourself sometimes you check the wrong box and you didn't mean to.

20:18 So once you do the elimination all the way through 8 options, read back through the question one more time, check your answers, make sure you agree, make sure you have the right number of answers as the question told you to select and then you're ready to move on.

20:34 Now, we've got our next type of question that's possible in a case study.

20:38 Based on the client's assessment, which additional information is helpful to interpret the client's risk for potential issues? Okay, so it's asking me hey based on this particular client and this particular setting, which additional information is helpful if you do interpret the client's risk for potential issues? Now, look at this on the right hand side. Here's what we're going to select the answers and do the work.

21:07 Left hand side gives us information. Right hand side is where we do the work.

21:12 So you see that you've got the assessment. We've got 1, 2, 3, 4, 5, 6 of those but then look at the 3 columns next to it.

21:21 We've got 3 possible diagnoses. Pulmonary embolism, coronary artery disease, and hypovolemic shock.

21:30 One of those has to be the most likely. But before we move to that, we're trying to compare the symptoms and what the patient has and think through what might this be.

21:41 You know I think I already know what it is. Okay, that's great.

21:45 But when you're taking this question, they're asking you "Do you know the symptoms of the other 2 diagnoses also?" So, even if you feel like I am sure what this gentleman is experiencing, you still have to do the work of these other questions.

21:59 So, let's blow it up bigger for you so you can see it.

22:03 On the left, we've got chest pain, shortness of breath, high blood pressure, O2 sat 89%, diminished pulses on the lower extremities, and 1+ peripheral edema.

22:13 Now, it's asking us to take each of those symptoms and either say yes or no for the 3 diagnoses.

22:20 Now, you can do this a couple of ways. You can either go diagnosis by diagnosis or you could go symptom across all 3 columns.

22:27 It really doesn't matter because I'm going to ask you to do it both ways.

22:32 Now, for this stake we're going to work through it first by looking diagnosis by diagnosis.

22:37 And we're going to start with pulmonary embolism because that's the first one on the left.

22:42 Okay, there's no magic to this but the more systematic you are on things, the more consistent your results will be.

22:48 So since pulmonary embolism is the first one up, let's do it. So, pulmonary embolism and chest pain.

22:56 Would I expect them to have chest pain with pulmonary embolism? Well, a pulmonary embolism is I got this big clot in my lungs. That's why it's called pulmonary embolism.

23:10 Remember the number 1 cause of those is usually a deep vein thrombosis, travels up through the leg, kind of goes through the heart, ends up getting into the lungs and causing a blockage in a vessel.

23:22 Might be complete, might be partial, but that could definitely cause chest pain especially if that heart is having to work in an overload because now that right ventricle is trying to push blood over to the lungs and you've got this cork in the lungs in the form of an embolism.

23:41 Now, as we're still working down our column of pulmonary embolism, shortness of breath.

23:46 Is that possible with the pulmonary embolism? Yeah, yeah, it really is and if the patient is coming and seeking care, we know that this patient has shortness of breath.

23:55 Could that be caused by a pulmonary embolism? Yeah, it really could. Because remember that clot or that embolism is in the lung bed, right.

24:04 It's in the vasculature of the lungs. So, blood is not able to flow through there as freely as we need it to flow through therefore there is not as much oxygen available to the patient.

24:14 So, yeah an embolism decreases the amount of oxygen in the blood and that could be, the shortness of breath could be, caused by a pulmonary embolism.

24:24 Now, high blood pressure. In a pulmonary embolism, you don't necessarily anticipate high blood pressure unless it's really a severe case.

24:33 Now when we talk about cases of pulmonary embolisms, there are usually 3 types of patients.

24:39 There is one where they have a pulmonary embolism and they don't even know it.

24:45 The second type, they have a pulmonary embolism and they're having these symptoms that we're talking about. Short of breath can be painful.

24:54 There's a 3rd group that has a pulmonary embolism and it's a quick death. It causes their death.

25:00 So, those are usually someone who is in the hospital, we observe them or they don't usually make it alive to the hospital.

25:08 So, not everyone who has a pulmonary embolism knows about it.

25:11 Not everyone who has a pulmonary embolism feels symptoms, and not everyone who has a pulmonary embolism dies.

25:20 But it's pretty traumatic when you see someone experience one that's so massive it does cause their death.

25:26 So, the high blood pressure would really have to be a severe one that's not normally an indication of a pulmonary embolism.

25:34 Now O2 sat of 89%, we know that's a little low.

25:38 Yes, that would be common in pulmonary embolism because they've got that clot in their lungs, they're not able to move through the blood supply, it's not getting oxygenated enough.

25:49 So you have inadequate blood oxygen being delivered through to the rest of the body.

25:55 That's what's causing their shortness of breath and a saturation of 89%. Let's take a look at diminished pulses on the lower extremities.

26:05 Is that connected to pulmonary embolism? Well, diminished pulses like they're less than normal, usually means it's not really strong perfusion to that extremity.

26:16 That's not typically a sign of pulmonary embolism. You might see that with hypovolemia. Right? If less volume, your pulses are going to be weaker but not typically a sign with pulmonary embolism.

26:29 What about 1+ peripheral edema? Well, this could be because when you think about it, if you have a big blood clot in your lung, it's the right side of your heart that pumps blood into your lung.

26:43 If you have a big enough clot in your lung, that right side of your heart is going to have to work extra hard to get blood over to the heart.

26:53 So, somebody with increased workload on the right side of their heart might start to show the symptoms of right-sided heart failure.

27:01 Remember that's everything backing up this way. And 1+ peripheral edema could be a sign of right-sided cardiac workload being elevated.

27:10 That means we would check yes. This could be associated with pulmonary embolism.

27:18 Now, we've got pulmonary embolism done. You do another quick read through and see if that makes sense to you.

27:24 Now, we go on to coronary artery disease. So with coronary artery disease, would you expect chest pain? Oh yeah, that's a common sign.

27:31 So yes. We would check chest pain. What about coronary artery disease and shortness of breath? Yes, that makes sense because there's inadequate oxygen being supplied to the body's tissues.

27:44 What about high blood pressure with coronary artery disease? Oh, yeah of course. They go hand in hand.

27:52 Because when you have coronary artery disease, you have plaque build-up in your vessels.

27:57 That makes your vessels really stiff. It's caused by atherosclerosis and so you tend to have higher blood pressure depending on how severe the coronary artery disease is.

28:09 What about an O2 sat of 89%? Well, that's a sat below normal. It could also indicate really inadequate oxygenation.

28:19 So could that be associated with coronary artery disease? Yeah, it could. What about diminished pulses on the lower extremities? Now, we know that this indicates poor perfusion. Could that be a problem with coronary artery disease? Well, those vessels are filling up with all kinds of plaque. Right? And also you've got these vessels that are stiff so yes poor perfusion could be a sign of coronary artery disease.

28:49 Now, 1+ peripheral edema. It's mild. Right? That's not a big deal but it could indicate inadequate heart pumping.

28:59 We're ready for the 3rd diagnosis of hypovolemic shock. Hypo means low, volemic talks to volume.

29:07 So hypovolemic means you're in shock which whatever causes shock means there's inadequate oxygen being delivered to the tissues.

29:15 So, hypovolemic shock is caused by low intravascular volume. So let's walk through these same symptoms and see if they have a connection to hypovolemic shock.

29:28 Now, could you have chest pain in hypovolemic shock? Hey, that's not typically a symptom seen with hypovolemic shock unless it is severe.

29:38 So, since it's not generally seen like if we really extrapolated and made a movie and thought through, we might be able to make a case for it but they're expecting you to know what you generally see with a diagnosis.

29:51 Now, what about shortness of breath? Yes, you're going to see shortness of breath with hypovolemic shock because you don't have enough volume to move oxygen around to the tissues. Alright, so we know that shortness of breath is an answer we would check.

30:07 Now, high blood pressure. Oh no, that would not be hypovolemic shock because when I have low volume, I have lower blood pressure.

30:17 I would not be hypertensive like this client is. I would be hypotensive. So I'm not going to check high blood pressure.

30:28 O2 saturation of 89%. Could that happen with hypovolemic shock? Well , yeah because we know that definition of shock is that you're not getting enough oxygen delivered to the tissues.

30:42 This patient is reporting shortness of breath and they have this O2 saturation of 89% so yes, we're going to check this symptom.

30:51 Now, diminished pulses on the lower extremities. Would this be associated with hypovolemic shock? Yeah, less volume means diminished pulses. So diminished volume equals diminished pulses.

31:08 And lastly, we've got 1+ peripheral edema. Is this associated with hypovolemic shock? No.

31:16 Hypovolemia would not usually cause peripheral edema. Okay? So, let's go back and review this.

31:24 What is going to be the best way for you to work through this? Well, we work through this pulmonary embolism, coronary artery disease, and hypovolemic shock.

31:34 We did it that way. What I'm going to ask you to do is to pause and work through the questions by symptom.

31:41 Okay, this was your final check to make sure everything is right.

31:44 I don't care if you work from 1+ peripheral edema up to the top or you start at the top and work down to the bottom, but go back and check your work.

31:52 Remember you get partial credit on this and you want every point. Okay? So, work your way through, take the first symptom and saying yes or no to pulmonary embolism, yes or no to coronary artery disease, yes or no to hypovolemic shock.

32:06 So work your way through that one more time to check your answers before you move on to the 3rd part of this case study. This is the 3rd part of the case study.

32:22 Remember each case study has 6 questions that all deal with the same patient situation.

32:28 Now, we're looking at this tab. You see we have the medication tab highlighted.

32:32 Again, you'll be able to click through any of those tabs that you want to but you also want to stay focused. Don't get really distracted.

32:40 On the left hand side, we've got information about the patient, kind of the cues or the clues.

32:46 On the right hand side is where we do the work. Now when you're looking at these boxes, you'll see they have select response. You got a little dropdown arrow.

32:54 And I'm going to show you what that looks like when you hit the dropdown arrow.

32:58 But we wanted you to be very clear, that's what the question will look like on the day you're taking an exam.

33:04 In the NCLEX format when you're sitting down and looking at that screen, this is what's going to be staring back at you.

33:10 An example that could be. So, when you click that dropdown arrow, look what you see.

33:16 So we've got 1, 2, 3, 4, 5 options. You'll pick the best one. We're going to show you what it looks like as we go through all of these. Right? You have the options there.

33:27 When you click the dropdown arrow, it gives you those to pick through. Now we have to do the work of putting them in the right order and what they map.

33:36 So you'll see on the left when we blown this up for you, we've got the conditions listed there.

33:41 Infection, myocardial infarction, stroke, deep vein thrombosis, and seizures. Those will be the options you have for the box that's on the top.

33:51 So, let's talk about this. Remember who our patient is? This 58-year-old person who came to ER. He has had chest pain.

33:58 It's turned ___ intermittent for 3 days, now it's become continuous. Diaphoretic. They've got an irregular heart rate.

34:05 They've got a pulse ox that's too low. A respiratory rate that's too high. We work through some potential diagnosis in the previous question. Right? Seeing which one seemed most probable with what we're doing? Now, we're going to look at and see what do we think this gentleman really has? What's his main problem? Well, they give us a sign of what about infection? Do we think the cause of all of his abnormal vital signs and pain is infection? Well, if it was infection he would likely have an elevated temperature. His temperature was normal.

34:39 So, I would not think this is caused by infection. Next option, myocardial infarction. Yeah, there are a lot of things.

34:48 When you look back at that list that we checked for myocardial infarction, he has chest pain, he has shortness of breath, he has an irregular heartbeat, and his pain was 8/10.

34:59 He has had a history of this happening for 3 days. He is also diabetic with a history of hypertension.

35:04 So, yes, there are a lot of signs that point to myocardial infarction. For now, I think that's the best answer particularly when compared to infection.

35:15 Now, let's look at the next option. Okay, why am I picking an answer and saying for now that's what I want? Everything is relative on the NCLEX. You have to treat this like it was a card game.

35:30 Can only play the hand that you're dealt so you may want some different answer, it doesn't matter.

35:35 The item writers are trying to see can you look at these options and pick the one that's the most logical and will keep the patient the safest.

35:44 So, so far myocardial infarction I'm feeling pretty good about that.

35:49 Stroke. Okay could these signs line up with stroke? Well, signs of stroke would be like numbness, paralysis, they might be confused. He doesn't have any of that.

36:01 He hasn't complained of numbness or weakness in the arms, face, or leg. He's not confused.

36:06 He is not having any difficulty speaking. So, no. I would rule out a stroke.

36:12 That would be like a bad diagnosis, but based on what I know about this gentleman, it's much more likely that he's having a myocardial infarction.

36:21 Now, deep vein thrombosis. Okay, the signs of that. So DVT is like down deep in my leg. Right? Deep vein thrombosis.

36:29 The things I might see as the patient might have, leg pain. The skin might be reddened around that.

36:35 He might have some swelling in that foot. Those could all be possible symptoms of DVT.

36:40 Now, I might have a decrease in capillary refill so that kind of gets my attention because I know that this patient had kind of a slow capillary refill and they did have that 1+ edema, but I don't see reddened skin around on this gentleman.

36:57 He doesn't tell me about leg pain and he has got an irregular heartbeat, short of breath, pulse ox of 89, and level of pain 8/10.

37:07 So, even though a deep vein thrombosis is bad and some symptoms might be the same, I still say myocardial infarction is showing us much more signs that it could be a myocardial infarction.

37:18 Now, what about seizures? Well, there are all different kinds and types of seizures, but there's really no evidence in his symptoms and in our assessment that he's experiencing seizures.

37:29 So, I've worked all the way through those, I feel really comfortable that it is myocardial infarction. Right? So we're going to put myocardial infarction in that first box. So you would click it and you would drag it all the way up there.

37:45 Now we've got 2 more boxes to fill in this question. Right? There are 3 total, one at the top.

37:51 Now the next part of the question is going to ask us "What's your evidence that you think this is myocardial infarction?" So, look at our options over there. We have chest pain. We have edema in the lower extremities.

38:04 We have shortness of breath. We have decreased capillary refill and hypotension.

38:09 Which of these would support that this patient is experiencing a myocardial infarction? Chest pain? Yeah that's a classic one. Right? So, I would definitely think I'm going to keep chest pain in there for now.

38:21 Edema in the lower extremities. Well, it was relatively mild, could have other causes.

38:27 So, that's not one of my top answers. What about shortness of breath? Oh, that could be definitely a sign of a heart attack of an MI.

38:36 So, so far I'm going to keep chest pain and shortness of breath and I'm going to compare those 2 answers to the rest of the answers.

38:44 Decreased capillary refill. Well, this definitely could indicate poor perfusion, but it's not a more clear sign of an MI than chest pain or shortness of breath.

38:54 So, it doesn't win. I'm not going to check that one. Lastly, hypotension.

39:00 Oohhh, this patient was hypertensive, 155/98, so I'm going to stick with the answers that I picked.

39:08 I'm going to say the client is in the highest risk for developing a myocardial infarction as evidenced by chest pain and shortness of breath.

39:17 Does that make sense? Well, even if your sentence makes sense altogether, if you get the top answer wrong, like if we go with something else besides myocardial infarction, you're really not going to get the rest correct.

39:30 So take your time with that first answer. Make sure it lines up and you can prove it with the symptoms your patient has had in the previous parts of the case study.

39:41 Alright now, we're going on to another portion of the case study.

39:45 So for each potential nursing intervention, click to specify where the intervention is indicated or contraindicated for the care of the client.

39:54 So if this client, this setting, you only have 2 options.

39:58 Yes you should do it, no you should not. Indicated means yes, contraindicated means no.

40:05 So, here are our options. We've got 5 options. Okay, so this kind of feels a little bit more like a select all that apply because you know when you read through those, you have to say yes or no for each option.

40:18 So, think of it just as that type of question. So based on what I know about this patient, should we place them in a supine position? We're going to say yes or no. Look at the other options. Obtain electrocardiogram. Yes or no? Provide supplemental oxygen. Yes or no? Administer nitrates. Yes or no? And then finally instruct increase fluid intake. Yes or no? Indicated or contraindicated? Okay, so let's break them down.

40:47 Start on the left and at the top. So for this particular patient, I'm going to put them in a supine position. A supine position, that's lying back.

40:57 No. No, no, I'm not going to do that and it's because the patient has breathing difficulty.

41:02 So I want to elevate them, probably even have them in like a high fowler's position, not on a supine position because I want to help support that respiratory status.

41:12 So, when you have them sitting up, you don't have this all his weight pushing down on their chest, it allows them to breathe easier and to expand their chest more.

41:20 So I'm going to elevate the head of the bed, not put them in a supine position. So what I check indicated or contraindicated? Good, contraindicated.

41:31 I don't put somebody who's having respiratory distress in a lying down position.

41:38 Let's look at obtain an electrocardiogram. Oh yeah, I'm definitely going to get one of those.

41:44 This gentleman is having irregular heartbeat. We know he's in respiratory distress. He said he has chest pain. We're going to get an ECG.

41:51 Now, someone asked me the other day "Is an ECG the same thing as an EKG?" Yes, you'll hear those terms used interchangeably, but you can see why we call it an ECG because that's a better breakdown of the English word.

42:03 So, we want this 12-lead ECG so we can get an idea of what exactly is going on in the electrical conduction system of the heart.

42:12 We can determine what's the next best thing to do. So, no to supine, yes to ECG. Supplemental oxygen.

42:23 Hey, this patient has an oxygen sat less than 90% and you might be saying ah, ah, ah I heard that we don't always give stat oxygen on everybody we think is having an MI.

42:32 You're right, we don't. But this gentleman is different, he doesn't have a normal oxygen saturation.

42:38 He's below 90% which is why this would be indicated to start oxygen on him in the ER. Administer nitrates.

42:48 Hey that's a cool thing. Right? We have nitrates. You're going to open and dilate those vessels. We're going to help decrease the workload of the heart. That's a good thing.

42:57 And for chest pain, we're going to give this to the patient. So that would be indicated. Instruct to increase fluid intake. Okay, let's think about that.

43:07 Ahm, we think they're having a heart attack. We think that they're really having some issues probably with perfusion and oxygenation. So, no.

43:19 This patient would likely be NPO. We don't want to load extra fluid on-board and they might be having some test or a heart cath.

43:26 We don't want to increase their fluid intake. And really, their blood pressure is already high. Increasing fluid intake is not going to help them.

43:34 So, that would be contraindicated. Now that you've worked your way all the way through each one of these 5 potential interventions, check one more time.

43:45 Supine position? No, contraindicated because they can't breathe. Obtain electrocardiogram? Yes, indicated because we think he's having an MI. Provide supplemental oxygen? Yes, indicated because his sat is lower than 90% and he is breathing at a rate of 24.

44:01 Administer nitrates? Yes, indicated because of the cardiac chest pain.

44:05 And then last one. Instruct to increase fluid intake? No, contraindicated because he may have testing or something else going on and fluid is not going to help him at this point.

44:15 So, he'd likely would be NPO, contraindicated. Okay, so there's your strategy on this type of question.

44:25 Now let's move on to the orders that the physician or the healthcare provider which can be a nurse practitioner, a midlevel provider, a physician's assistant, or a physician can write these orders.

44:38 They all have the privileges to write these type of orders. So let's take a look at it.

44:42 You see that it's 13:15, that's 1:15 in the afternoon. 0.9% sodium chloride 1 liter to keep vein open rate.

44:54 So that means 1 liter of fluid but you're going to run it at just a tiniest slowest rate, just enough to keep that vein open but not to fluid overload the patient.

45:04 O2 2 liters per minute via nasal cannula.

45:08 Does that make sense to us? Sure does because we know that the sat is lower than normal, we know that we're putting that on and so that's good.

45:15 Continuous cardiac telemetry? Oh yeah. Whatever type of unit this patient goes to, we want them on continuous cardiac monitoring.

45:24 When we say continuous cardiac telemetry, that means like a little box that we tuck in the pocket of their gown but it's going to give us continuous monitoring of that patient's electrical activity of their heart.

45:35 Pulse oximetry monitoring? Yeah. They've just come in, their sat is too low, we put them on oxygen, we want to monitor that treatment so yes that sounds good.

45:44 Electrocardiogram? We've already established, that's a good idea. Vital signs every 30 minutes? Okay, kind of thinking about that.

45:51 Does that seem often enough? I don't know, let's keep that one in the back of our mind.

45:55 Nitro 0.4 mg sublingual q.5 minutes x3 or until chest pain is relieved? Okay, that could work.

46:08 A lot of places that once you get to 3 administration, 3 doses they're going to look at a different plan.

46:14 So if you're going past 3, you'd kind of want to talk to the healthcare provider about that. Aspirin 325 mg stat? That's because if we think it's a clot, they will help us take care of that as far as not allowing the clot to get bigger.

46:29 Morphine sulfate 5 mg IV q.2 hours p.r.n. for severe pain? So if we can't get that chest pain under control.

46:38 Okay and we've got these other medications on there. Can you see them? Yeah, clopidogrel.

46:42 This is a medication that we don't want the patient to have clots formed in the future.

46:49 If this is a myocardial infarction, it could be caused by a clot and so we want to make sure that after an event like this, a patient is at increased risk to develop more clots so we would put them on this type of medication for a certain period of time when we know it's the riskiest for them to have another event.

47:08 Atorvastatin is a statin medication the patient was already on and that seems good. And metoprolol tartrate. That is a beta-blocker.

47:17 They're going to give it IV push stat and repeat every 5 minutes until we meet those criteria.

47:24 Okay, that's a beta-blocker given at IV. Blood pressure was high. I'm pretty comfortable with everything on here.

47:31 They talk about the laboratory tests that are ordered.

47:34 A complete blood count, electrolytes, BUN. Like pretty much everything you could have on here. But the 2 at the bottom are a little bit different.

47:44 CKMB is a test for heart damage. Now, it's not as specific as that next test. Cardiac troponin stat and q.6 hours x24 hours.

47:56 So, if someone's coming in, they're being evaluated for a heart attack, we want them to stay for that full 24 hours so they can see what happens to that cardiac troponin.

48:04 So remember a CKMB will tell us some things but it is not as specific as a cardiac troponin test.

48:11 Now, let's look at what the question is going to ask us.

48:17 Remember this view? This is what the question will look like to you on the NCLEX exam. Alright.

48:21 So this is what you'll see that left side that has the tabs and information and on the right side is the actual options that we're picking from to select the answer choices.

48:32 So, on the left is information about the patient. On the right will be the answer choices that we're picking from.

48:40 Now, key about this type of format is it tells us how many answer choices we should pick. No, I'm not kidding.

48:47 It actually tells you how many answer choices are correct. We want to make sure you read that part very closely.

48:56 What's the number on this one? 4, correct. So the question says "The nurse reviews the orders from the HCP.

49:05 Click to highlight the 4 orders that the nurse needs to perform immediately." This is just another way of saying "What are the top 4 things or the 4 most important things the nurse needs to do immediately?" So, does that mean we're not going to do the other orders? No, it just means " Can you identify what are the 4 most important things that you should do right away for a patient in this particular setting with this particular diagnosis and symptoms?" Alright, so we're going to go through this one more time again. 0.9% sodium chloride 1 liter to keep vein open, KVO, keep vein open.

49:46 Well, would an MI is important for us to have venous access that's open? Yes.

49:52 So I'm thinking that's going to be one of them, but let's keep working through them.

49:57 O2 at 2 liters per minute via nasal cannula. Would this be a priority for somebody in this situation? What would make that a priority? Oh, pulse ox is low, respiratory rate is high, he's complaining of shortness of breath, can't finish a sentence.

50:12 Yeah, so far I'm going with the first two. Next, the continuous pulse ox. Oh I know he has had respiratory problems.

50:20 I think he has had an MI or working on having an MI so yes I'm going to put a continuous pulse ox on immediately so I can keep an eye on where he is in his oxygen status. ECG. Is that something I should do immediately? He does have that irregular heart rate. He has chest pain 8/10. Yes, we need to figure out if he is having an MI.

50:44 An MI is involving. Is it a stemmy? Is it a non-stemmy? So, so far I'm going to go with that one also.

50:52 Now, vital signs every 30 minutes. Well, for giving nitro we would take it more often than that and really vital signs in 30 minutes should be done but that's a period of time.

51:03 So, it doesn't trump the other 4 that we picked. Nitroglycerin 0.4 mg sublingual q.5 minutes x3 or until chest pain is relieved. Ohhhh.

51:18 Wait a minute. Yeah, this guy's having chest pain. It would make sense that we give ntiro.

51:23 Okay, so now I have it at 5. That's okay. Right? I'm not sure which of those I'm going to get rid of, I'm just going to keep this 5 and we'll come back to it.

51:33 Now, aspirin. I know it's important that they get it, but is it more important than the 5 we've already checked? This is where you have to make the decision. No. We're going to give aspirin, I know it's important part of it but it doesn't trump the other things that we're doing right now.

51:49 Morphine sulfate 5 mg IV q.2 hours p.r.n. severe pain. Hhmmm, we're going to give that if we can't address it with the nitroglycerin but it's not my immediate go to with chest pain.

52:05 Oohhh, here's that medication that will stop clots from getting bigger. Is that my immediate response? No.

52:12 We'll give it but that's not going to be what we do immediately. It doesn't trump the others that we've picked.

52:18 A statin lowers cholesterol. That's not an immediate stat type intervention so we'll give it but not our highest priority.

52:26 Metoprolol tartrate. Look we've got a blood pressure medication. Right? That's a beta-blocker. So that's going to reduce the workload of the heart.

52:36 But is that one of our top 4 things? No.

52:42 You go back through all of those and look again at the priorities and see what you think is the most important.

52:52 Now I have a dilemma. Right? I picked 5 things that I want to do but the question only asked me for the top 4 things.

53:02 So now I've got to figure out which one I'm going to eliminate and this is going to happen to you. That's just how it works.

53:09 So, stay calm, know that you expected this and let's just do the work. So, is an IV more important that oxygen? No.

53:19 Is an IV more important than a continuous pulse ox? No. The IV is not going to tell me how they're doing on oxygen.

53:26 I know they're in a little bit of respiratory distress. No. Is an IV more important than an ECG? No.

53:33 Because we got to figure out this person is having an actual evolving MI. And is an IV at TKO more important than nitroglycerin? Is that going to address the chest pain and the ischemia? No.

53:46 So even though I want to have an IV and I want it that right there and ready to go, it's asking me to pick the 4 most important things that I can do to keep this patient safe in this particular setting and so I'm going to have to let the IV go and know that we'll get it done but more importantly is get that oxygen on, make sure it's working, figure out they're having a stemmy and non-stemmy and make sure we give the nitro to help address the chest pain.

54:14 So, you might think that's not how I would pick or what I would do and I want to do that other thing.

54:20 Don't get wrapped up in that. That will just confuse you and it won't help you do well on the exam.

54:26 Know that the question is just asking me what the 4 things are because they're always checking to see if a student can prioritize. All those orders will be implemented.

54:35 And in real life I hope you have your whole ___ friends just to sending on that room and knocking out all those orders at the same time.

54:43 Fortunately, we don't have that advantage when you're taking the NCLEX, but know that don't waste energy being frustrated on the exam.

54:52 Just do your best one question at a time. Now, this is going to get a little more exciting.

54:58 Now, look at the nurse's notes. Remember, you'll see a different format when you're taking the exam. We're just blowing this up for you.

55:04 So 13:18. Wow, not much time has passed. You got the orders, O2 is applied. 2 liters by nasal cannula. IV access is obtained.

55:13 Wait a minute. Didn't we just say it was? Remember, all those orders we're going to be done, going to be implemented.

55:20 Don't think you should've changed an answer. This is just giving you an update on all the things that were done.

55:26 The previous question just asked you what are the 4 most immediate things to do? Okay, so don't let your ____ self. So you got O2 on. We've got IV access in the left vein. We've got IV fluid started, no sign of IV-related complications.

55:44 Remember, it's just going at KVO anyway, I wouldn't expect complications. The client was placed in a high fowler. Cool.

55:52 That's a high fowler position because of their difficulty with breathing. That's what we want. Nitroglycerin 0.4 mg sublingual x1 for the pain, 6 out of 10.

56:03 We also gave him the aspirin. We gave him the other medications. You see them all listed there.

56:08 Blood pressure is still a little higher than we'd like it, 156/90. "Client states," we know that's important.

56:18 The client states upper chest pain has decreased to 4/10. Hey, cool. He came in at 8/10.

56:24 We gave him some nitro, 6/10. Now he's 4/10. We're heading in the right direction.

56:31 Blood pressure is also decreased, 148/86. Still a little high but much better than where we were when he first came in.

56:42 Now, it's 7 minutes later at 13:25, did the ECG showing ST elevation. Okay, this lets us know we really got something going on.

56:52 Then we have to alert the provider, we know there's a total blockage somewhere in one of the coronary arteries and that the heart muscle is currently dying.

57:01 Right? It is taking a hit. This is a myocardial infarction. Blood was drawn for the labs, the pain is rated 4/10 still in the upper chest area, but we're ahead of where we were, 8/10 when they came in.

57:16 But we got some really important information at 13:25. What is the most life-threatening information here? The ST segment elevation.

57:26 We know there's something really serious going on and so we need to make sure that we intervene quickly for this patient.

57:34 So by 13:40, 1:40 pm, client's awake and oriented x3 (person, place, and time), sitting up in bed, they appeared to be comfortable.

57:43 Their breathing is not labored anymore and they're not diaphoretic. That's all good news.

57:49 Client states I feel a little better. And he rates the chest pain as a 4 on a 1-10 scale still in the upper chest area and he said it's much less than it was.

58:01 Skin is pink. Remember they were pale before. And now it's dry and warm so they're not as diaphoretic.

58:07 Capillary refill is 3 seconds. Okay, so that's a little better. Right? It was more than 3 seconds before.

58:14 Client is now able to speak full sentences without shortness of breath. Absence of adventitious sounds is noted upon auscultation of the lungs bilaterally.

58:24 Wow. That's a mouthful. See? This is what we did to you on the NCLEX exam. Why you couldn't just say clear breath sounds bilaterally? That would make much more sense to most of us. But prepare yourself, there's going to be some pretty fancy pretentious language on the exam sometimes.

58:41 Slow down, ask yourself "What does that mean?" Alright, so if we don't have any weird breath sounds going on there, we know he's not likely in pulmonary edema.

58:51 We don't hear crackles, we don't hear rhonchi. So, we're doing pretty good. Last, let's take a look at the vital signs.

58:58 Temperature 97.52 Fahrenheit. That's still within normal range. Heart rate 88, hey that's good. Respiratory rate 18.

59:08 So that's decreased. Excellent. Blood pressure 129/95, again still high, but much better than where we were before.

59:17 Pulse ox is reading 90%. Okay, we haven't made such tremendous progress there, but it's better and he's feeling better.

59:26 Respiratory rate is down so we're feeling good about that progress. The nurse has performed the interventions as ordered by the physician.

59:35 Which assessment data shows the client's symptoms improved? Select all that apply.

59:42 Hey, I want you to go back to that last sentence.

59:45 We know the last sentence always kind of cues us because it says "client's symptoms improved." Does it say normal? No. It says are they improved? So we're going to select all that apply, it doesn't tell us how many are correct.

1:00:01 So we're kind of on our own. So let's look at these 6 symptoms together. I'm going to start in the upper left hand corner.

1:00:09 Capillary refill. So, what was the capillary refill when the patient came in? It was greater than 3 seconds. We know that was abnormal.

1:00:19 Now, it's 3 seconds. So, is that a sign of improvement? Yes. 3 seconds is within normal limits so that's a sign of improvement.

1:00:31 Does that mean everything is well? No. But the question was asking we're looking for signs of improvement.

1:00:38 Next, let's look at respiratory rate. Well, when they came in it was like 24, they couldn't finish a sentence.

1:00:44 They had all those challenges but now respiratory rate is within normal limits. We also know that the patient was appearing much more comfortable.

1:00:54 So I'm going to show this as a sign of improvement. So I'm going to check capillary refill so far and check respiratory rate.

1:01:02 Those are both signs of improvement. Pulse ox. Okay, this one gets a little sketchy. Right? Because the pulse ox was 89% and now it's ooohhh all the way up to 90%. Now, that's still not normal.

1:01:17 We'd like them to be 94% or higher; however, the question asked me "Did it demonstrate improvement?" So while it's not a big deal, it's only 1% improvement, it's still an improvement. So I would check that box.

1:01:32 And hopefully you don't get any questions on the NCLEX that are that razor-thin close. But in this case, I would definitely check pulse oximetry.

1:01:41 Now pain rating. When he came in it was an 8 and then we got it down to a 6 and we got it down to a 4. So that definitely indicates improvement.

1:01:50 Wow, things are looking kind of good, huh, with those options. What about the neuro assessment? What? Neuro assessment like this guy came in and we think he had a heart attack.

1:02:00 Why his neuro assessment coming up now? It's just a distractor. He was awake and alert and oriented the whole time for when he came in and that has not changed.

1:02:11 So, a neurological assessment is not going to show us improvement because it wasn't abnormal in the first place so I would not check neurological assessment.

1:02:21 Now finally, got these specific vital signs at temperature of 97.52. This is still normal.

1:02:30 So it doesn't indicate an improvement, it just means it's still within normal limits so I would not select this answer.

1:02:38 So let's go back and review. Capillary refill? Yes because it is 3 seconds now instead of greater than 3 seconds.

1:02:45 Respiratory rate? Yes because it's down from 24 that's showing us improvement.

1:02:51 Pulse oximetry, not amazing results but it did go from 89-90.

1:02:56 Pain rating, ooohhh from 8-4, fantastic so we're up to 4 options I would check.

1:03:02 Neuro and temp always have been normal, remain normal. I would not select those.

1:03:08 So once I've done that all through, I know I'm good to go and to submit this final part of the case study. Congratulations.

1:03:17 If you hang with me through each one of those options, hopefully you learned about your own test-taking strategies.

1:03:24 Which things are going to be the most difficult to discipline yourself to think through slowly? Now, I promise when you take these questions as you practice, you'll be much faster than you and I walking through this together but I wanted to give you an example of what a case study would look like.

1:03:42 What it would look like on your screen for NCLEX? What it looks like for us when we blow it up and dissect it and work through this is altogether because we want to help you be successful on your NCLEX.

1:03:55 One time is all I want anyone to have to go through that test. So goodluck and join us for our other NCLEX review videos.