ATI NUR 209 Final Assessment

Correct Answer: 

Maintain a calm, caring, professional demeanor

Ask the teen if she feels safe

Contact the police

Interview the client privately

Explanation:

Maintain a calm, caring, professional demeanor :

It is crucial to maintain a calm and professional demeanor when assessing a potential abuse case. The nurse should create an environment that is non-judgmental, allowing the teen to feel comfortable sharing her experience. This approach helps build trust, particularly when the teen may be reluctant to disclose abuse.

Ask the teen if she feels safe :

The nurse should inquire directly if the teen feels safe at home or in her relationship. This is an important step in identifying any potential danger or ongoing abuse. It’s essential to ask this question in a non-threatening, supportive way, ensuring the teen knows she has options and support.

Contact the police :

When signs of physical abuse are suspected, it is important to follow mandatory reporting guidelines. This includes contacting the police and other relevant authorities to ensure the teen is protected. The nurse must prioritize the safety of the patient and involve the appropriate authorities when abuse is suspected.

Interview the client privately  :

The nurse should interview the teen privately, without the presence of the boyfriend or any other individuals who might be involved in the potential abuse. This ensures the teen can speak openly without fear of retribution, manipulation, or intimidation.

Why the Other Option is Incorrect:

Confront the boyfriend about possible abuse :

While it is important to assess the situation, confronting the boyfriend directly in front of the teen is not recommended. This could escalate the situation and put the teen at greater risk. The nurse should instead focus on ensuring the teen's safety and gather information in a private and supportive setting.

Summary:

The most appropriate interventions for a nurse suspecting abuse include maintaining a calm, professional demeanor, asking the teen if she feels safe, conducting a private interview, and contacting the police to ensure the teen's safety. Confronting the boyfriend is not advisable, as it could escalate the situation and put the teen at further risk.

Correct Answer: Gradual weaning of breastfeeding

Explanation:

Gradual weaning of breastfeeding (Correct):

Gradually weaning from breastfeeding is not a direct cause of mastitis. In fact, gradual weaning is often recommended as it helps prevent complications like engorgement or sudden milk stasis. Mastitis is more commonly caused by issues such as infrequent feedings, cracked nipples, or engorgement. A sudden cessation or abrupt weaning may increase the risk of milk stasis, but gradual weaning itself is not a typical cause.

Why other options are incorrect

Infrequent, inconsistent feedings (Incorrect):

Infrequent or inconsistent feedings can lead to milk stasis, which increases the risk of mastitis. When the milk isn't emptied properly from the breasts, it can become stagnant, leading to an infection in the breast tissue. This is a common cause of mastitis.

Cracks or fissures of the nipples (Incorrect):

Cracks or fissures in the nipples are a common cause of mastitis because they can provide an entry point for bacteria, leading to infection. Proper latch and nipple care are essential to prevent this.

Engorgement from oversupply of milk (Incorrect):

Engorgement occurs when there is an oversupply of milk, and it can lead to mastitis. When the breasts are not emptied properly, milk can accumulate, leading to swelling, pain, and a higher risk of infection.

Summary:

The correct answer is B. Gradual weaning of breastfeeding because this is not typically a direct cause of mastitis. The other options, such as infrequent feedings, cracked nipples, and engorgement, can contribute to mastitis due to milk stasis or infection risk

Correct Answer: Dysmenorrhea that is unresponsive to NSAIDs

Explanation

Endometriosis is a condition where endometrial-like tissue grows outside the uterus, commonly on the ovaries, fallopian tubes, and pelvic peritoneum. A hallmark symptom of endometriosis is dysmenorrhea (painful menstruation) that is severe and not relieved by typical treatments, such as NSAIDs or oral contraceptives. The pain often worsens over time and may interfere with daily functioning. This type of refractory menstrual pain is a key clinical clue in the diagnosis of endometriosis.

Why xother options are  incorrect:

An atypical Papanicolaou smear at her last clinic visit 

An abnormal Pap smear can suggest cervical cell changes related to HPV or other cervical pathology, but it is not associated with endometriosis, which involves endometrial tissue, not cervical tissue.

Abdominal bloating starting several days before menses 

While bloating can occur as a premenstrual symptom, it is not specific to endometriosis and is more commonly associated with general PMS or GI issues. It lacks the diagnostic specificity of severe, treatment-resistant dysmenorrhea.

A history of pelvic inflammatory disease (PID) 

PID is an infection-related condition of the upper genital tract that can cause pelvic pain and infertility, but it is not causally related to endometriosis. The two conditions can share overlapping symptoms (e.g., pelvic pain), but PID is not a risk factor or indicator of endometriosis.

Summary:

Option D is correct because persistent, severe dysmenorrhea unresponsive to NSAIDs is a classic and reliable symptom associated with endometriosis. The other options either lack specificity or pertain to unrelated conditions.

Correct Answer: Blood pressure 144/94 mm/Hg in left arm

Explanation :

At 36 weeks' gestation, the nurse must closely monitor for signs of complications, including pre-eclampsia or hypertension. A blood pressure of 144/94 mm/Hg is considered elevated and falls under the category of hypertension. This can be indicative of gestational hypertension or pre-eclampsia, which requires immediate intervention to prevent further complications such as organ damage or preterm labor.

A blood pressure of 140/90 mm/Hg or higher is considered significant and should be reported to the provider right away to ensure the mother and fetus receive appropriate care.

Why the Other Options Are Incorrect:

O negative blood type :

O negative is a Rh-negative blood type, and while it requires administration of Rh immunoglobulin (RhoGAM) at specific points during pregnancy (e.g., at 28 weeks and after delivery if the baby is Rh-positive), it is not an immediate cause for concern unless the client experiences bleeding or other complications. It does not require immediate reporting to the provider in this case.

Positive rubella serum antibody titer :

A positive rubella serum antibody titer indicates immunity to rubella and means the client has been exposed to rubella or has been vaccinated. This is not a cause for immediate concern, as it actually means the client is immune and has protective antibodies, which is a positive finding during pregnancy.

Copious leukorrhea :

Leukorrhea is a normal finding during pregnancy and refers to increased vaginal discharge. It is generally clear or milky and occurs due to hormonal changes. While an increase in discharge can be alarming if accompanied by itching, odor, or color changes, copious leukorrhea alone without other symptoms is typically normal and does not require immediate reporting.

Summary:

The blood pressure of 144/94 mm/Hg (D) should be immediately reported to the provider as it may indicate hypertension or pre-eclampsia, conditions that need prompt intervention. The other findings (O negative blood type, positive rubella titer, and copious leukorrhea) do not require immediate reporting to the provider.

Correct Answer: The newborn with a respiratory rate of 72 breaths/minute

Explanation

A respiratory rate of 72 breaths/minute in a 3-hour-old newborn is above the normal range and requires notification of the provider. The expected respiratory rate for a newborn is 30 to 60 breaths per minute. A rate of 72 indicates tachypnea, which may be a sign of respiratory distress, sepsis, transient tachypnea of the newborn (TTN), or other underlying conditions. Although some degree of transient tachypnea is not uncommon in the first few hours after birth, persistent tachypnea beyond the first hour, particularly if greater than 70, can indicate a potentially serious condition and must be reported.

Why other options are incorrect

Why The newborn with a heart rate of 154 beats/minute is incorrect:

A heart rate of 154 beats per minute is within the normal range for a newborn. The expected heart rate for a newborn is between 110 and 160 beats per minute while asleep or quiet. Therefore, there is no need to notify the provider in this situation.

Why The newborn with a red raised capillary hemangioma on left forearm is incorrect:

A red, raised capillary hemangioma on the forearm is commonly known as a strawberry hemangioma. It is a benign vascular birthmark that typically appears in the first few days to weeks of life. These usually resolve on their own without treatment and do not require immediate medical attention unless they interfere with vital functions (e.g., vision, breathing, feeding), which is not indicated here.   

Why The newborn with whitish, hardened nodules on the gums of the mouth is incorrect:

Whitish, hardened nodules on the gums of a newborn are most likely Epstein's pearls, which are common and benign inclusion cysts found in the mouths of many newborns. They are harmless, typically resolve spontaneously, and do not require provider notification.

Summary:

Option A is the correct answer because a respiratory rate of 72 is above the normal newborn range and may indicate a pathological condition requiring immediate medical evaluation. The other findings are within normal limits or represent common benign newborn conditions that do not warrant provider notification.

Correct Answer: G5 T2 P1 A1 L2

Explanation

G5 (Gravida): This refers to the total number of pregnancies, including the current one. The client has had 5 pregnancies:

2010: Spontaneous abortion at 8 weeks.

2015: Normal spontaneous vaginal delivery (NSVD) at 41 weeks.

2018: NSVD at 39 weeks.

2020: Cesarean section of twins at 35 weeks (one twin, baby B, died in the NICU, but it still counts as one pregnancy).

2024: Currently pregnant with twins.

So, G5.

T2 (Term births): This is the number of full-term births (37 weeks or later). The client had two term births:

2015: NSVD at 41 weeks.

2018: NSVD at 39 weeks

So, T2.

P1 (Preterm births): This is the number of preterm births (between 20-36 weeks). The client had one preterm birth

2020: Cesarean section of twins at 35 weeks.

So, P1.

A1 (Abortions): This is the number of pregnancies lost before 20 weeks. The client had one spontaneous abortion:

2010: Spontaneous abortion at 8 weeks.

So, A1.

L2 (Living children): This is the number of living children. The client has 2 living children:

One living child from the 2015 pregnancy.

One living child from the 2018 pregnancy.

The 2020 pregnancy resulted in twins, but baby B died in the NICU, so only 1 living child from that pregnancy (twin A survives).

Therefore, the client has 2 living children (not 3).

So, L2.

Why other options are wrong

G4 T2 P1 A1 L3: This option is incorrect because the client has 5 pregnancies (G5), not 4.

G5 T2 P0 A1 L3: This option is incorrect because the client had 1 preterm birth (P1) in 2020, not 0.

G4 T2 P1 A1 L3: This option is incorrect because the client has 5 pregnancies (G5), not 4.

Summary:

The correct GTPAL calculation is G5 T2 P1 A1 L2 because the client has had 5 pregnancies, 2 full-term deliveries, 1 preterm delivery, 1 abortion, and 2 living children. The other options are incorrect due to discrepancies in the number of pregnancies, preterm births, or living children.

Correct Answer:

Creases covering soles of feet

Cracked, peeling skin

Explanation:

Cracked, peeling skin :

Due to the prolonged exposure to amniotic fluid in the uterus, a postmature infant is likely to have dry, cracked, and peeling skin. This is a common finding in postmature infants as they lose the protective vernix and their skin starts to dry out.

Why other options are wrong

Vernix in the folds and creases :

In a postmature infant, vernix (the protective, waxy coating on the skin) is typically minimal or absent. Vernix is usually present in preterm and early term infants, and its presence decreases as the pregnancy progresses beyond term.

Short, soft fingernails :

In a postmature infant, the fingernails are typically longer and may be more firm than those of a preterm infant. Fingernails in postmature infants often extend beyond the fingertips. Therefore, short, soft fingernails would not be expected in this case.

Creases covering soles of feet:

A postmature infant has more prominent creases on the soles of the feet due to the prolonged duration in utero. The skin is more developed, and the feet are often completely covered with creases.

Positive Moro reflex :

The Moro reflex (or startle reflex) is typically present in all infants, regardless of gestational age. Its presence would not be specific to a postmature infant. It is not a distinguishing characteristic of postmaturity.

Summary:

The correct answers are C. Creases covering soles of feet and E. Cracked, peeling skin, which are typical findings in postmature infants due to the extended duration in utero. The other findings, such as vernix, short fingernails, and Moro reflex, are either more characteristic of preterm or term infants and not specific to postmaturity.

Correct Answer: Performing regular weight-bearing exercises

Explanation:

Performing regular weight-bearing exercises :

Weight-bearing exercises (like walking, jogging, or strength training) are crucial for menopausal women to help prevent osteoporosis and maintain bone health. These exercises stimulate bone formation and help maintain bone density, which is particularly important due to the decline in estrogen during menopause.

Why other options are incorrect

Decreasing the intake of dairy products :

While dairy products are important for calcium intake, decreasing dairy is not typically emphasized for menopausal women unless they have a specific intolerance or medical condition. Dairy products, particularly those high in calcium, are actually beneficial in preventing osteoporosis.

Limit alcohol and caffeine intake :

Limiting alcohol and caffeine can help reduce the severity of hot flashes and may improve sleep, but it is not the most important self-care measure for menopausal women. While it's beneficial, it doesn't address the key issues like bone health.

Taking vitamin E and B complex vitamin supplements :

While vitamin E and B complex vitamins may provide some benefits for menopausal symptoms (like hot flashes or mood stabilization), they are not as important as regular exercise for maintaining long-term health, particularly bone health, in menopausal women.

Summary:

The most important self-care measure for a menopausal woman who opts not to use hormone therapy is C. Performing regular weight-bearing exercises, as this helps maintain bone density and prevent osteoporosis, a key concern for women during and after menopause. The other options are beneficial but not as crucial for long-term health.

Correct Answer: Pancreatic enzymes will not be necessary if our child has a good appetite and regular bowel movements

Explanation:

Playing on the backyard swings and running around outside are exercises our child will really enjoy

Children with cystic fibrosis (CF) need regular physical activity to help promote lung function and overall health. Play and exercise are encouraged, and outdoor activities like playing on the swings or running are beneficial for both physical and respiratory health.

Why the Other Options are Wrong. 

A high-protein, high-calorie diet may need to be supplemented with a high-calorie formula

Children with CF often have trouble absorbing nutrients due to pancreatic insufficiency. A high-calorie, high-protein diet is critical, and they may need a high-calorie formula or supplements to meet their nutritional needs. This statement is accurate and reflects appropriate education.

Pancreatic enzymes will not be necessary if our child has a good appetite and regular bowel movements

This statement is incorrect. Even if a child with CF has a good appetite and regular bowel movements, they still need pancreatic enzymes with meals to help with digestion and absorption of nutrients. CF affects the pancreas, and without enzymes, even if a child appears to have a normal appetite, they may not properly absorb fats and nutrients. The statement shows a misunderstanding of the need for pancreatic enzyme therapy.

Three to four times a day we will perform chest therapy and postural drainage on our child 

Chest physiotherapy (chest therapy) and postural drainage are essential for children with CF to help clear mucus from the lungs and improve respiratory function. Performing these therapies 3-4 times a day is standard for CF management. This statement is accurate and reflects proper education.

Summary:

The statement C. Pancreatic enzymes will not be necessary if our child has a good appetite and regular bowel movements suggests a misunderstanding of cystic fibrosis care. Pancreatic enzyme replacement therapy is always necessary in CF, regardless of appetite or bowel movements, to aid in proper digestion and nutrient absorption. The other statements are consistent with proper education for CF care.