ATI NUR 209 Final Assessment

Correct Answer: The client puts the number of the crisis center into their phone.

Explanation:

The client puts the number of the crisis center into their phone (Correct):

This is the most concrete action and demonstrates that the client has engaged with the safety plan provided by the nurse. By saving the crisis center’s number, the client has made an active decision to keep the resource accessible in case they need it. This indicates a proactive step toward ensuring their safety, which is the most effective way to evaluate the client’s response to the safety plan.

Why other options are incorrect

The client thanks the nurse for the information (Incorrect):

While thanking the nurse for the information is a polite response, it does not indicate that the client has taken any action or feels empowered to act on the information provided. Evaluating the client’s response requires a more concrete action, such as making use of the resources offered.

The client explains they are not planning to leave their home (Incorrect):

If the client indicates that they do not plan to leave their home, it could be a sign that they may not feel ready or safe enough to take further action at the moment. This statement does not reflect engagement with the safety plan, and further support or intervention may be required.

The client thinks their home will be safer now that there is a baby in the house (Incorrect):

This statement suggests the client may not fully understand the dynamics of intimate partner violence (IPV) and how it can affect the household, regardless of the presence of a baby. IPV often escalates during significant life events, like childbirth, and the belief that a baby will make the home safer is not a realistic understanding of the issue. The client may need further education and support.

Summary:

The most appropriate way to evaluate a client’s response to a safety plan for intimate partner violence is through concrete actions that demonstrate the client is engaging with the plan, such as saving the crisis center’s contact number. This shows that the client has considered the plan and has taken steps toward ensuring their safety.

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 Answers:

Handwashing,

Use of barrier protection

Perineal care of genital lesions

Explanation why they are correct:

Handwashing 

Good hand hygiene is essential in preventing the spread of the herpes virus to other parts of the body or to other people. Patients should wash their hands thoroughly after touching lesions or applying topical treatments to reduce the risk of autoinoculation (spreading the virus to eyes or other mucous membranes).

Use of barrier protection 

Using condoms or other barrier methods during sexual activity reduces the risk of transmitting HSV-2 to sexual partners, although it may not eliminate the risk entirely. Patients should also avoid sexual contact during outbreaks, when the virus is most contagious.

Perineal care of genital lesions 

Proper perineal hygiene helps prevent secondary infections and promotes comfort and healing of herpes lesions. Patients should be advised to keep the area clean and dry, wear loose-fitting clothing, and avoid irritating products.

Why other options are incorrect:

Gardasil injection

The Gardasil vaccine protects against human papillomavirus (HPV), not herpes simplex virus (HSV). While it is important for young people to be vaccinated against HPV, it does not treat or prevent HSV-2.

Penicillin 

Penicillin is an antibiotic, which is ineffective against viral infections like HSV-2. Treatment for HSV involves antiviral medications such as acyclovir, valacyclovir, or famciclovir.

Summary:

The correct answers are A, C, and E. These address infection control, prevention of transmission, and care of active lesions. Gardasil and penicillin are not appropriate for managing or treating HSV-2.

Correct Answer: Offer fluids to your child multiple times every day.

Explanation:

Children with sickle cell anemia are at risk for dehydration, which can trigger a sickle cell crisis by causing the sickle-shaped red blood cells to clump together more easily. To prevent dehydration and reduce the risk of further complications, it is crucial to encourage the child to drink fluids frequently throughout the day. This helps to maintain adequate blood volume and reduce the likelihood of sickling of red blood cells, thereby preventing another crisis.

Why the Other Options Are Incorrect:

Monitor your child's temperature daily:

While monitoring for signs of infection (such as fever) is important, daily temperature checks are not specifically indicated for all children with sickle cell anemia. Fever is an important symptom to watch for, especially during a sickle cell crisis, but it is not a daily requirement. The focus should be on preventing crisis triggers like dehydration, infection, or excessive activity.

Apply cold compresses when your child expresses pain :

Cold compresses can actually increase vasoconstriction and may worsen the pain during a sickle cell crisis. The recommended approach for managing pain in sickle cell anemia is to use heat (warm compresses) or pain-relief medications, as warmth helps to relax muscles and improve blood flow. Cold compresses are generally not used in this scenario.

Restrict outdoor play activity to 1 hour per day :

While children with sickle cell anemia need to avoid activities that may cause excessive fatigue or dehydration, there is no specific restriction to 1 hour of outdoor play. Instead, the focus should be on ensuring the child stays hydrated and does not become overheated or too tired during physical activities. The goal is to maintain a balance of activity without overexertion.

Summary:

The most important teaching for a child with sickle cell anemia after a crisis episode is to offer fluids frequently (D). Hydration helps to prevent dehydration, a major trigger for sickle cell crises. The other interventions, such as monitoring temperature or applying cold compresses, are not as appropriate for the management of sickle cell anemia or pain during a crisis.

Correct Answers:

The language used should reflect the education level of the learners

Adolescents respond better to active learning like games

Explanation of the Correct Answers:

The language used should reflect the education level of the learners

This is essential in all educational settings. When teaching adolescents, nurses should use age-appropriate language and avoid complex medical terminology unless it’s clearly explained. Tailoring the language ensures comprehension and keeps learners engaged.

Adolescents respond better to active learning like games

Adolescents are more likely to engage with educational content when it is interactive. Incorporating games, role-play, and multimedia can make learning more fun and relevant. Active learning strategies help retain attention and improve knowledge retention in this age group.

Explanation of Why the Incorrect Options Are Wrong:

There are no changes needed

This is incorrect because adolescents and adults learn differently. Teaching methods must be adapted to meet developmental and cognitive levels, interests, and attention spans of different age groups.

Adults respond better to pictures

While visual aids can be useful for all learners, there is no evidence that adults specifically respond better to pictures than adolescents. In fact, adolescents often benefit more from visual and interactive content due to shorter attention spans and a need for stimulation.

Summary:

When teaching adolescents compared to adults, the nurse should adjust both the language to match education level and use active learning strategies like games to enhance engagement. These modifications support effective and age-appropriate education.

Correct Answer:

Fetal motion

Amniotic fluid volume

Fetal breathing

Explanation :

A biophysical profile (BPP) is a test used to assess the health of a fetus, particularly in high-risk pregnancies. It involves an ultrasound to observe fetal movements, breathing, tone, and the amount of amniotic fluid, along with a nonstress test (NST) to assess fetal heart rate and reactivity. The BPP score is based on five variables, each scored on a scale of 0 to 2, and the total score helps guide decisions about further management

Fetal Motion :

One component of the BPP involves assessing fetal movements, which can indicate how well the fetus is developing and if it is receiving enough oxygen. The presence of fetal movement is a positive sign.

Score: The fetus gets a score of 2 for normal movements, or 0 for abnormal or absent movements.

Amniotic Fluid Volume :

The amount of amniotic fluid is assessed as part of the BPP. Low amniotic fluid (oligohydramnios) can indicate fetal distress or other complications, while adequate fluid suggests good fetal well-being.

Score: A score of 2 indicates adequate amniotic fluid, while 0 means insufficient fluid.

Fetal Breathing :

The BPP also assesses fetal breathing movements. A fetus should demonstrate breathing-like movements during the test, as this indicates adequate oxygenation.

Score: 2 for normal breathing movements and 0 if absent.

Why A and E are Incorrect:

Fetal Gender :

Fetal gender is not part of the biophysical profile. While it can be determined via ultrasound, it is not a focus of the BPP, which is concerned with the fetus's health indicators, not its gender.

Fetal Neck Translucency :

Fetal neck translucency (often assessed during the first trimester as part of screening for chromosomal abnormalities) is not a component of the BPP. The BPP focuses on fetal movement, breathing, tone, fluid volume, and heart rate reactivity, not on anatomical features like neck translucency.

Summary:

The biophysical profile (BPP) assesses fetal motion (B), amniotic fluid volume (C), and fetal breathing (D) to determine fetal well-being, while fetal gender (A) and fetal neck translucency (E) are not part of this assessment. Therefore, the correct answers are B, C, and D.

Correct Answer: I need to leave the diaphragm in for six hours after the last act of intercourse

Explanation:

The diaphragm should be left in place for at least 6 hours after intercourse, but no longer than 24 hours to avoid complications such as urinary tract infections (UTIs) and toxic shock syndrome (TSS). This ensures that the diaphragm remains effective in preventing sperm from entering the cervix.

Why the Other Options are Wrong:

This contraceptive can be used during menstruation (Incorrect): A diaphragm should not be used during menstruation. Using it during a period increases the risk of infections and can compromise its effectiveness. The diaphragm should be removed before the menstrual cycle begins to ensure safety and proper functioning.

I can leave the diaphragm in for a day or two (Incorrect): The diaphragm should not be left in for more than 24 hours. Leaving it in for extended periods increases the risk of infections, such as toxic shock syndrome (TSS) and urinary tract infections (UTIs). It should be removed within 24 hours after intercourse to maintain safety.

Once I am fitted for the diaphragm it will always be the correct size (Incorrect): The diaphragm's size can change over time due to factors such as weight changes, pregnancy, childbirth, or pelvic surgery. Therefore, it’s important to have regular check-ups with a healthcare provider to ensure the diaphragm still fits properly and provides adequate contraception.

Summary

The correct use of a diaphragm involves leaving it in for at least 6 hours after intercourse but no longer than 24 hours. The other statements indicate common misconceptions about the diaphragm's use, such as using it during menstruation, leaving it in for too long, and assuming the fit remains the same indefinitely. Proper education is crucial to ensure effectiveness and safety when using the diaphragm for contraception.

Correct Answer: Obtain fetal heart rate

Explanation:

Obtain fetal heart rate:

The first priority when a client presents in labor with ruptured membranes, frequent contractions, and bloody show is to assess the fetal heart rate. This helps to determine whether the fetus is tolerating labor and whether there are any signs of distress that need immediate intervention. Fetal heart rate monitoring provides critical information about fetal well-being.

Why the Other Options are Wrong:

Perform a sterile vaginal exam :

Although a sterile vaginal exam is important for assessing cervical dilation and fetal station, it is not the priority. The fetal heart rate should be assessed first to ensure that the fetus is not experiencing any distress that could require immediate action.

Establish IV access :

While establishing IV access is important for managing fluids and medications during labor, it is not the priority. The fetus' well-being should be assessed first by obtaining the fetal heart rate to guide further interventions.

Assess the client's vital signs:

While assessing the mother's vital signs is important, it is not the first priority in this scenario. The fetus' well-being should be the primary concern initially, so obtaining the fetal heart rate is the first step.

Summary:

The priority intervention is to obtain the fetal heart rate, as it helps to assess fetal well-being and guide further actions during labor. The other interventions, while important, are secondary to this initial assessment.

Correct Answer: Massage the fundus until it firms

Explanation :

After delivery, the fundus should be firm and contracted to prevent postpartum hemorrhage. If the fundus is soft and spongy, it indicates that the uterus is not contracting effectively, which can lead to increased bleeding. The first step in management is to massage the fundus to stimulate uterine contraction. This will help the uterus firm up and reduce the risk of hemorrhage. Massage should be done in a gentle but firm manner to encourage the uterus to contract.

Why the Other Options Are Incorrect:

Document the fundal height and consistency :

While it is important to document the findings, it is not the first intervention. If the fundus is soft, immediate action needs to be taken (i.e., massaging the fundus) rather than just documenting the assessment.

Notify the healthcare provider :

Notifying the healthcare provider is important if the massage does not resolve the issue or if the bleeding increases, but it is not the first step. The nurse should first attempt to massage the fundus to address the issue directly.

Administer Oxytocin IV per MD orders :

Oxytocin is typically given to promote uterine contractions and help control bleeding. However, the first intervention for a soft and spongy fundus is to massage the uterus, which may be sufficient to firm the fundus. If massaging the fundus does not work, then medication such as Oxytocin can be considered, but it should not be the first action.

Summary:

The first intervention when assessing a soft and spongy fundus postpartum is to massage the fundus until it firms (C). This will help stimulate uterine contractions and prevent potential complications like postpartum hemorrhage. Documenting, notifying the provider, and administering medication are important actions but should follow after the initial intervention.