ATI NUR 211 Final Assessment Fall Exam

Correct Answer:

Wear a mask when caring for the client.

Place the client in a private room.

Encourage the client to increase fluid intake.

Explanation of the Correct Answers:

Wear a mask when caring for the client: Influenza B is transmitted through respiratory droplets when the infected person coughs, sneezes, or talks. To protect both the nurse and others from potential transmission, wearing a mask is a necessary precaution while caring for the client. This helps reduce the risk of spreading the virus.

Place the client in a private room: Influenza B is contagious, and placing the client in a private room helps prevent the spread of the virus to other patients in the healthcare setting. This practice limits exposure and reduces the risk of transmission to vulnerable individuals.

Encourage the client to increase fluid intake: Increased fluid intake helps the body manage fever, prevent dehydration, and thin mucus and secretions. Staying hydrated is essential for the client’s recovery from influenza and will help alleviate symptoms such as sore throat and muscle aches.

Explanation of Why the Other Options Are Incorrect:

Prepare to administer an antibiotic to the client: Since the diagnosis is influenza B, which is a viral infection, antibiotics are not effective. Antibiotics target bacterial infections and would not address a viral illness like influenza. Instead, antiviral medication such as oseltamivir (Tamiflu) might be considered if prescribed by the provider.

Place the client on airborne precautions: Influenza is spread through respiratory droplets, not airborne particles, so airborne precautions are not required. Airborne precautions are necessary for diseases like tuberculosis or measles, which spread through the air. The correct precaution for influenza is droplet precautions.

Summary:

To prevent the spread of influenza B and support the client’s recovery, the nurse should wear a mask, place the client in a private room, and encourage fluid intake. Antibiotics are not appropriate for viral infections, and airborne precautions are unnecessary for influenza.

Correct Answer:  Ecchymosis

Explanation of the Correct Answer: 

Idiopathic thrombocytopenic purpura (ITP) is a condition characterized by low platelet count, which can lead to easy bruising and bleeding. Ecchymosis refers to bruising, which is a common manifestation in clients with ITP due to the insufficient number of platelets available to help with blood clotting. The nurse should closely monitor for signs of ecchymosis as it indicates bleeding under the skin and can signify a risk for more severe bleeding episodes.

Explanation of Why the Other Options Are Incorrect:

Elevated WBC

Elevated white blood cell (WBC) count is typically a sign of infection or inflammatory conditions, but it is not directly related to ITP. ITP is primarily characterized by a low platelet count rather than changes in WBC levels. An elevated WBC would not be the main concern in this case unless there were signs of infection.

Fever

Fever is not a typical or primary symptom of ITP, as the condition itself does not directly cause fever. While a fever could potentially occur if there is an underlying infection or complication, it is not the most significant manifestation to monitor in a client with ITP. The nurse should be more concerned with signs of bleeding (such as ecchymosis) due to the low platelet count.

Fatigue

Fatigue can occur in many conditions, including ITP, but it is not as specific or critical to monitor as ecchymosis. Fatigue can result from anemia or other factors, but bleeding manifestations, such as ecchymosis, are more directly related to the pathophysiology of ITP and require more urgent monitoring.

Summary:

The correct answer is A, as ecchymosis (bruising) is a primary manifestation of idiopathic thrombocytopenic purpura (ITP) due to the low platelet count and the risk of bleeding. The other options (elevated WBC, fever, and fatigue) are not as directly related to the monitoring needs of a client with ITP.

The correct answer is : Receive a yearly influenza vaccination

Explanation:

Sickle cell disease (SCD) leads to splenomegaly (enlargement of the spleen) and puts patients at increased risk of infection, especially due to functional asplenia (loss of spleen function) over time. The spleen is crucial for filtering bacteria from the bloodstream, so vaccination is an essential part of managing the risks associated with SCD. Annual influenza vaccination is strongly recommended for all individuals with SCD to prevent respiratory infections, which can trigger a sickle cell crisis and cause further complications.

Why the other options are wrong:

Avoid drinking large amounts of fluids

This is incorrect. Hydration is crucial in sickle cell disease, as dehydration increases blood viscosity, promoting sickling and exacerbating pain and crisis. The client should be taught to maintain adequate fluid intake, especially during illness or hot weather, to help prevent sickle cell crises.

Eat six small meals daily instead of large meals

While frequent meals can be helpful in managing fatigue or maintaining energy levels, this is not the primary discharge instruction for sickle cell disease management related to splenomegaly. The focus should be on overall nutrition and staying well-hydrated rather than specific meal frequency unless there is a particular need (such as appetite issues).

Engage in aerobic 3 days a week

While exercise can be beneficial for overall health, intense or strenuous physical activity should be avoided during a crisis or when the patient has splenomegaly or abdominal pain. Physical activity should be moderate and guided by the physician, as high exertion can worsen sickling episodes. This instruction is not directly relevant for a client with acute abdominal symptoms and splenomegaly.

Summary:

The most important instruction for discharge in this case is to receive a yearly influenza vaccination to help prevent infections, which are a major risk for patients with sickle cell disease, especially those with splenomegaly or compromised spleen function. Proper hydration, avoiding large fluid deficits, and consulting with the physician regarding exercise plans should also be part of comprehensive management, but they are secondary to infection prevention.

Correct Answer:  Excessive thrombosis and bleeding

Explanation of the Correct Answer: 

Excessive thrombosis and bleeding – Disseminated intravascular coagulation (DIC) is a serious condition characterized by widespread activation of the clotting cascade, leading to the formation of blood clots in small blood vessels throughout the body. These clots can block blood flow to organs, leading to organ damage. At the same time, the excessive clotting depletes clotting factors and platelets, causing bleeding in other parts of the body. This simultaneous clotting and bleeding is the hallmark of DIC and explains the excessive thrombosis and bleeding observed in affected clients.

Explanation of Why the Other Options Are Incorrect:

Increased clotting factors – In DIC, clotting factors are actually consumed and depleted, not increased. The ongoing clotting process uses up these factors, leading to their deficiency and the subsequent bleeding tendencies. Increased clotting factors would not be expected in this condition.

Progressive increase in platelet production – While platelet counts can initially be elevated in the early stages of DIC, they typically become very low as platelets are consumed in the clotting process. This results in thrombocytopenia, not a progressive increase in platelet production. Low platelet counts contribute to the bleeding tendencies seen in DIC.

Immediate sodium and fluid retention – Sodium and fluid retention are not typical findings of DIC. DIC primarily involves abnormal clotting and bleeding, and while it may cause some organ dysfunction (such as renal failure), sodium and fluid retention are not the primary or expected findings in this condition. Fluid management would be based on individual client needs, particularly with regard to renal function, but this is not a defining feature of DIC.

Summary:

The correct answer is A, excessive thrombosis and bleeding, as this is the characteristic presentation of DIC, where widespread clotting and bleeding occur simultaneously. The other options do not accurately reflect the pathophysiology or typical findings of DIC.

The correct answer is : Decorticate posturing

Explanation:

This posture is characterized by flexion of the arms, wrists, and fingers, with adduction of the upper limbs (arms pulled in toward the body), internal rotation of the legs, and plantar flexion of the feet. It typically indicates damage to the cerebral hemispheres, internal capsule, or thalamus, and it represents a disruption in the brain’s motor pathway above the level of the brainstem. While still serious, decorticate posturing is usually considered less severe than decerebrate posturing in terms of neurological prognosis.

Why the other options are wrong:

Decerebrate posturing:

This posture is characterized by extension and pronation of the arms, rigid extension of the legs, and plantar flexion, with arms and legs held straight out, wrists rotated outward, and head arched back. It indicates brainstem damage, specifically below the level of the red nucleus (midbrain or pons), and is associated with a poorer neurologic outcome than decorticate posturing.

Atypical hyperreflexia:

This refers to exaggerated reflex responses, such as seen in conditions like upper motor neuron lesions or spinal cord injuries. It does not describe a sustained postural response like what is seen in decorticate or decerebrate posturing.

Spinal cord degeneration:

Degeneration of the spinal cord may result in symptoms like muscle weakness, atrophy, loss of coordination, or spasticity, but it does not lead to fixed posturing such as that described in this scenario. The findings in the question are specific to central nervous system (brain) injury, not spinal cord degeneration.

Summary:

The flexion of the upper limbs and internal rotation of the lower limbs observed in this client are classic signs of decorticate posturing (A), which indicates significant neurologic injury above the brainstem. This is a serious sign that requires immediate medical attention and documentation.

Correct Answers:

The client has had gastric bypass surgery

The client has had treatment for gastrointestinal cancer.

The client has ulcerative colitis.

Explanation of the Correct Answers:

The client has had gastric bypass surgery – Gastric bypass surgery can lead to reduced absorption of nutrients, including iron. The surgery often results in decreased stomach acid and a shortened digestive tract, which can interfere with iron absorption and increase the risk of iron deficiency anemia.

The client has had treatment for gastrointestinal cancer – Treatment for gastrointestinal (GI) cancer, such as chemotherapy or radiation, can damage the GI tract and impact nutrient absorption. Additionally, surgeries related to GI cancer (such as partial gastrectomy or bowel resections) can lead to malabsorption of iron, increasing the risk of iron deficiency anemia.

The client has ulcerative colitis – Ulcerative colitis, an inflammatory bowel disease, can cause chronic blood loss through the intestines, leading to iron deficiency anemia. The inflammation and bleeding in the gastrointestinal tract can deplete iron stores over time.

Explanation of Why the Other Options Are Incorrect:

The client eats red meat daily – Red meat is a good source of heme iron, which is easily absorbed by the body. Eating red meat daily does not increase the risk of iron deficiency anemia; in fact, it may help prevent it. Therefore, this finding is not a risk factor for iron deficiency anemia.

The client eats mostly prepackaged, processed foods – While prepackaged and processed foods may be lower in nutrients like iron, the risk of iron deficiency anemia is more closely related to inadequate iron intake or malabsorption. This option alone does not specifically indicate a risk for iron deficiency anemia unless the client's diet is also low in iron-rich foods.

Summary:

The nurse should identify the client's history of gastric bypass surgery, treatment for gastrointestinal cancer, and ulcerative colitis as possible risk factors for iron deficiency anemia. The other findings, such as eating red meat daily and eating mostly prepackaged, processed foods, do not directly increase the risk for iron deficiency anemia

Correct Answer:  Antiplatelet aggregate

Explanation of the Correct Answer:

Antiplatelet aggregate – Aspirin is primarily prescribed for its antiplatelet effect, which helps reduce the formation of blood clots by inhibiting the aggregation (clumping) of platelets. This action is particularly important in clients with a history of myocardial infarction (MI), as it decreases the risk of further clot formation that could block coronary arteries, leading to another heart attack. By inhibiting platelet aggregation, aspirin reduces the likelihood of thrombus (clot) formation in the arteries, which is a key factor in preventing additional cardiovascular events.

Explanation of Why the Other Options Are Incorrect: 

Antipyretic – While aspirin does have antipyretic (fever-reducing) properties, this is not the primary reason it is prescribed for clients with a history of MI. The antiplatelet effect is the more important therapeutic action in this case, as it addresses the prevention of clot formation, which is the primary concern after an MI.

Analgesic – Aspirin does have analgesic (pain-relieving) properties, but again, this is not the primary reason for its use in clients with a history of MI. In the case of an MI, aspirin is used for its antiplatelet effect to prevent further cardiovascular events, not for managing pain. Analgesic properties are typically more relevant for conditions like mild to moderate pain.

Anti-inflammatory – While aspirin does have anti-inflammatory properties, especially at higher doses, its primary role in preventing further heart attacks after a myocardial infarction is through its antiplatelet effect. The anti-inflammatory properties are secondary to its action on platelet aggregation, which is the primary therapeutic effect for this indication.

Summary:

The correct answer is A, antiplatelet aggregate, because aspirin is prescribed to reduce the risk of clot formation in clients with a history of myocardial infarction by inhibiting platelet aggregation. Although aspirin has other effects, such as antipyretic, analgesic, and anti-inflammatory properties, its main use in this case is to prevent further cardiovascular events by inhibiting platelet aggregation.

Correct Answer:  Use an electric razor while on this medication.

Explanation of the Correct Answer:

Use an electric razor while on this medication – Warfarin is an anticoagulant that increases the risk of bleeding by inhibiting clot formation. Because of this, clients are at higher risk for bruising and cuts from even minor injuries. Using an electric razor instead of a traditional blade helps minimize the risk of accidental cuts, which could lead to excessive bleeding. This is an essential safety precaution and a standard part of discharge education for clients on warfarin therapy. Additional precautions include using a soft-bristled toothbrush and avoiding contact sports or activities with a high risk of injury.

Explanation of Why the Other Options Are Incorrect:

Increase fiber intake to reduce the adverse effect of constipation – While fiber intake is generally good for overall health and preventing constipation, constipation is not a common adverse effect of warfarin. Therefore, this instruction is not directly relevant to the medication’s side effects or safety considerations. It would be more appropriate in teaching about medications such as opioids or iron supplements, which can cause constipation.

Mild nosebleeds are common during initial treatment – This is incorrect and dangerous. Nosebleeds, even if mild, are not considered a normal or expected effect of warfarin. Any signs of bleeding—including nosebleeds, bleeding gums, or blood in urine/stool—should be reported to the provider immediately, as they may indicate that the client's INR is too high, placing them at risk for serious hemorrhage.

If a dose of the medication is missed, double the dose at the next scheduled time – This instruction is incorrect and unsafe. Clients should never double up on warfarin doses. Doing so could lead to an excessive anticoagulation effect and increase the risk of bleeding. If a dose is missed, the client should take it as soon as they remember, but if it’s close to the time for the next dose, they should skip the missed dose and resume the regular schedule. The client should also notify the provider if multiple doses are missed.

Summary:

The nurse should include option A in the discharge teaching: using an electric razor is a critical safety measure for clients taking warfarin due to the increased risk of bleeding. Options B, C, and D are incorrect because they either provide unrelated, misleading, or potentially harmful instructions

The correct answer is : 0.9% normal saline

Explanation:

In sickle cell crisis, adequate hydration is essential to reduce blood viscosity and prevent further sickling of red blood cells. The most appropriate intravenous fluid for rehydration is 0.9% normal saline, an isotonic solution that effectively restores intravascular volume without causing significant fluid shifts or electrolyte disturbances. It improves tissue perfusion and helps reverse the sickling process. This is the standard fluid used in the acute management of dehydration in sickle cell crisis, especially in the emergency department setting.

Why the other options are wrong:

0.45% normal saline

This is a hypotonic solution and can lead to cellular swelling, including red blood cells. In patients with sickle cell disease, hypotonic fluids can worsen hemolysis and are not recommended during acute crisis when rapid volume expansion is needed.

Dextrose 50% (D50)

D50 is a hypertonic glucose solution used for severe hypoglycemia, not for rehydration. It does not address the volume deficit and could cause osmotic diuresis, potentially worsening dehydration.

Lactated Ringer’s solution

Although isotonic, lactated Ringer’s contains calcium and lactate, which may be less desirable in sickle cell patients, especially if there is a risk of renal dysfunction or if blood transfusions are anticipated, due to potential incompatibilities with citrate in blood products. It is not the first-line fluid in sickle cell crisis.

Summary:

The best fluid choice for a client in sickle cell crisis with dehydration is 0.9% normal saline due to its isotonic nature and effectiveness in restoring intravascular volume. Other fluids like 0.45% saline, D50, and lactated Ringer’s are either inappropriate for rehydration or carry risks that outweigh their benefits in this setting.