ATI NUR 211 Final Assessment Fall Exam

The correct answer is : 12

Explanation:

The Glasgow Coma Scale (GCS) is used to assess the level of consciousness based on three parameters: eye opening, verbal response, and motor response. Each component is given a score, and the total is used to determine the patient's neurological status. Here’s the breakdown of the GCS scores

Eye opening:

Spontaneous (4)

To speech (3)

To pain (2)

None (1)

Verbal response:

Oriented (5)

Confused (4)

Inappropriate words (3)

Incomprehensible sounds (2)

None (1)

Motor response:

Obeys commands (6)

Localizes pain (5)

Withdraws from pain (4)

Abnormal flexion (3)

Abnormal extension (2)

None (1)

For the client:

Eye opening: The client opens his eyes when the nurse calls his name, which is a score of 3 (to speech).

Verbal response: The client mumbles in response to questions, which is a score of 3 (inappropriate words).

Motor response: The client follows simple commands, which scores 6 (obeys commands).

Adding these together: 3 (eye opening) + 3 (verbal response) + 6 (motor response) = 12.

Why the other options are incorrect:

8: A score of 8 typically indicates a moderate impairment of consciousness, which would involve more serious impairment in either motor, verbal, or eye opening responses than what is described here.

10: This would typically be the result if the verbal or motor response were slightly worse, for example, incoherent speech or less purposeful motor responses.

14: This score would reflect a less impaired state, usually corresponding to a higher level of consciousness with only minor impairments in verbal or motor responses.

Summary:

The most accurate GCS score for this client is 12 because of the responses for eye opening (3), verbal response (3), and motor response (6).

The correct answer is : Creatinine: 2.9

Explanation:

A creatinine level of 2.9 mg/dL is significantly elevated and indicates potential renal impairment, which is a serious complication in clients with sickle cell disease (SCD). SCD can lead to chronic kidney disease due to repeated episodes of sickling that impair renal blood flow and damage the glomeruli. A normal creatinine level in adults typically ranges from 0.6 to 1.3 mg/dL. A value of 2.9 suggests a critical reduction in kidney function, requiring immediate provider notification to initiate or adjust management and prevent further renal deterioration.

Why the other options are wrong:

Hematocrit: 30%

While a hematocrit of 30% is below the normal range (typically around 36–48% in females and 40–52% in males), this value is expected in clients with SCD due to chronic hemolysis. Unless there is an acute drop or associated signs of crisis, this level does not require immediate reporting.

Sodium: 147

A sodium level of 147 mEq/L is slightly above the normal upper limit (135–145 mEq/L), but this is a mild elevation that is not typically urgent. It may reflect mild dehydration, which is common in SCD, especially during vaso-occlusive crises. It should be monitored, but it is not a critical value demanding urgent provider notification.

WBC: 12,000

A white blood cell count of 12,000/mm³ is just above the normal range (4,500–11,000/mm³), and in clients with SCD, mild leukocytosis is common due to chronic inflammation or recent stress such as pain or mild infection. It is not uncommon or immediately alarming unless accompanied by signs of sepsis or severe infection.

Summary:

The most urgent and abnormal lab value is the creatinine of 2.9, which signals significant kidney dysfunction, a known and serious complication of SCD. The other values are either expected findings in SCD or only mildly elevated and do not require immediate provider notification.

Correct answer: Blood pressure

The nurse is evaluating the client's response to the prescribed medications. The client's blood pressure and HDL level indicate an improvement in the client's condition.

Explanation:

Blood pressure: The client's blood pressure has improved from 180/88 mm Hg two months ago to 138/70 mm Hg today, which indicates a positive response to the prescribed medications (particularly atenolol and spironolactone, which are used to manage hypertension and fluid retention).

HDL level: The client's HDL (High-Density Lipoprotein) level has increased from 25 mg/dL two months ago to 60 mg/dL today. An increase in HDL, often referred to as "good cholesterol," is beneficial for cardiovascular health, suggesting a positive response to the prescribed statin (simvastatin).

Why the Other Options Are Incorrect:

Weight: Although the client’s weight has increased (from 86 kg to 90 kg), this may indicate worsening fluid retention due to edema rather than an improvement.

Potassium level: The potassium level has increased slightly from 4.2 mEq/L to 5.3 mEq/L. While this is within the normal range, the higher potassium level could indicate potential complications of spironolactone (a potassium-sparing diuretic). Monitoring is necessary.

Heart rate: The client's heart rate has decreased from 96/min two months ago to 58/min today. While this could be a result of atenolol, a beta-blocker, it should be monitored carefully because a heart rate below 60/min (bradycardia) can be concerning.

Pedal findings: The pedal edema has worsened (from 2+ to 3+), indicating persistent or worsening fluid retention, which requires further evaluation.

The correct answer is: It is unlikely you will become addicted when taking medicine for pain.

Explanation:

 It is unlikely you will become addicted when taking medicine for pain:

This is the best and most therapeutic response because it addresses the client’s concern directly and with empathy, while also educating them. When pain medications, including opioids, are used appropriately for cancer-related pain, the risk of addiction is very low. Patients with cancer are often undertreated for pain due to fear of addiction, so it is essential for nurses to clarify this misconception. This statement provides reassurance, facts, and promotes pain management as a right and essential part of care.

Why the other options are incorrect:

I will ask the provider to change your medication to a drug that is less potent:

This response does not address the root concern, which is fear of addiction, not the potency of the medication. Also, reducing the potency may result in inadequate pain control, which can diminish quality of life.

Would you like me to use music therapy to distract you from your pain?:

While music therapy can be a helpful adjunct for pain control, it should not be suggested as a substitute for pharmacologic pain relief in a cancer patient. This answer minimizes the client's pain and avoids addressing the real concern.

Would you like me to give you acetaminophen (Tylenol) instead?:

Acetaminophen is not sufficient for moderate to severe cancer pain. Offering a less effective medication due to a misconception reinforces the fear rather than resolving it and may lead to undertreatment of pain.

Summary:

The correct approach is to acknowledge the client’s fear, provide accurate information, and support effective pain management. Telling the client that addiction is unlikely when taking medication appropriately for cancer pain is both reassuring and empowering, making option C the best choice.

The correct answer is : Malignant cells enter the cell cycle frequently, making cell division continuous.

Explanation:

Malignant cells enter the cell cycle frequently, making cell division continuous:

This accurately describes why malignant (cancer) cell growth is uncontrolled. In normal cells, cell division is tightly regulated, and most cells enter a resting phase (G₀) where they do not divide unless triggered. Malignant cells, however, frequently re-enter the cell cycle, bypassing these regulatory checkpoints, which leads to continuous, unregulated proliferation. This constant cycling through the phases of cell division results in tumor growth and spread.

Why the other options are wrong:

Cancer cells always divide more rapidly than normal cells:

This is not necessarily true. Some cancer cells divide at rates similar to or only slightly faster than normal cells. What makes them dangerous is that they do not stop dividing, not necessarily that they divide faster. The issue is uncontrolled, persistent division, not speed alone.

Mitosis of malignant cells usually produces more than two daughter cells:

This is incorrect. Mitosis, whether in normal or malignant cells, typically results in two daughter cells. The difference in cancer lies in the loss of control over when and how often mitosis occurs, not the number of cells produced per division.

Malignant cells bypass one or more phases of the cell cycle during cell division:

While malignant cells may have disrupted checkpoints, they do not literally skip entire phases. Instead, they may shorten or ignore regulatory controls in those phases. The full cell cycle still occurs, but control mechanisms are defective, allowing cells to proliferate without the normal checks for DNA damage or readiness to divide.

Summary:

The uncontrolled growth of malignant cells is primarily due to their tendency to frequently enter and re-enter the cell cycle, leading to continuous cell division (D). They do not always divide faster (A), do not produce more than two daughter cells during mitosis (B), and do not completely bypass phases of the cell cycle (C)—instead, they ignore or override regulatory controls.

The correct answers are

GCS of 8

Decerebrate posturing:

Diminished cognition:

Explanation:

When assessing a client with a brain tumor, certain signs and symptoms indicate urgent or deteriorating neurologic function that requires immediate communication with the health care provider. These include:

GCS of 8: A Glasgow Coma Scale (GCS) score of 8 is considered to indicate a severe impairment in consciousness. A GCS score of 8 or below suggests a significant alteration in neurological status and typically requires urgent intervention. A score of 8 often triggers concerns about impending coma or severe brain injury, necessitating rapid evaluation and intervention by the healthcare provider.

Decerebrate posturing:

This is a serious sign of brain dysfunction, particularly associated with brainstem damage. Decerebrate posturing, which involves the extended posture with rigidly extended limbs, is a sign of severe neurological impairment and can be indicative of increased intracranial pressure or brainstem injury. This requires urgent communication with the healthcare provider to manage the condition.

Diminished cognition:

Deteriorating cognition or a sudden decline in cognitive function can indicate increased intracranial pressure, worsening brain tumor effects, or other life-threatening complications. This finding requires urgent evaluation to prevent further neurologic damage.

Why the other options are incorrect:

Reactive pupils: Reactive pupils (pupils that constrict when exposed to light) are a normal finding. This indicates that the brainstem is functioning and does not immediately require urgent attention. However, unreactive pupils or unequal pupils could suggest brain herniation or other urgent concerns, but reactive pupils are not alarming on their own.

Uninhibited speech:

Uninhibited speech, or disinhibition, can occur in various conditions, including brain tumors affecting specific areas of the brain. While it may be concerning and could indicate frontal lobe involvement, it does not require urgent intervention on its own unless it is associated with other serious signs, such as altered consciousness or severe cognitive decline.

Summary:

Urgent communication with the healthcare provider is required for a GCS of 8, decerebrate posturing, and diminished cognition, as these findings indicate significant neurological impairment that requires immediate attention. Reactive pupils and uninhibited speech are not immediately urgent findings.

The correct answer is : I know I can take care of all these needs by myself.

Explanation:

When caring for a loved one with a severe traumatic brain injury (TBI), it's essential that the caregiver recognizes the need for support and assistance. Statement A indicates a lack of awareness about the potential physical, emotional, and psychological challenges associated with caregiving for someone with a severe TBI. The spouse may be underestimating the intensity and complexity of the care required, and this may lead to burnout or neglect of their own health and well-being.

Why the other options are appropriate:

I need to seek counseling because I am very angry: This statement shows self-awareness of the emotional toll that caregiving can take. It’s important for caregivers to seek counseling or therapy if they are feeling anger, frustration, or any other overwhelming emotions. This is a healthy response to the stresses of caregiving, and the nurse should support this decision.

Hopefully things will improve gradually over time: This reflects a hopeful outlook, which is common when caregivers anticipate gradual improvement. It’s important for caregivers to have realistic expectations, but it’s also essential to maintain hope and a positive outlook during the recovery process.

With respite care and support, I think I can do this: This statement demonstrates that the spouse recognizes the importance of respite care and support systems, which is a healthy and practical approach to caregiving. Seeking help through respite care will help prevent caregiver burnout.

Summary:

The nurse should be concerned about statement A, as it suggests the spouse may not recognize the demands of full-time caregiving. Further education on the importance of seeking help and utilizing available resources (such as respite care and support networks) is necessary to prevent caregiver burnout and ensure the well-being of both the caregiver and the patient.

The correct answer is : Be aware of the early symptoms of crisis

Explanation:

Sickle cell anemia is a chronic, genetic blood disorder characterized by episodes of sickle cell crisis, during which sickle-shaped red blood cells block blood flow, leading to severe pain, organ damage, and other complications. Early recognition of the symptoms of a crisis is essential so that the client can seek appropriate medical attention promptly to manage pain and avoid complications. Symptoms of a crisis may include severe pain, fever, swelling in the joints, and fatigue, among others.

Why the other options are wrong:

Eat a diet high in iron

A diet high in iron is not recommended for individuals with sickle cell anemia unless they are iron-deficient because iron overload can occur, especially with regular blood transfusions, which is common in SCD management. It is important to avoid excessive iron intake and follow the dietary guidance of a healthcare provider to manage iron levels properly.

Take hydroxyurea every morning

Hydroxyurea is a medication used to help reduce the frequency of sickle cell crises, but it is not universally prescribed for all individuals with sickle cell anemia. If the healthcare provider has prescribed hydroxyurea, the client should take it as directed. However, it is not a routine medication for all individuals with sickle cell anemia, and the instructions should be tailored to the client’s specific treatment plan. The nurse should clarify whether this medication is needed for the client.

Do not use any oral contraceptives

While oral contraceptives can increase the risk of thromboembolism in some individuals, they are not automatically contraindicated for individuals with sickle cell anemia. However, this instruction must be given based on the client’s specific medical history and individual risk factors. Many women with sickle cell anemia can use oral contraceptives safely with the proper precautions. A discussion about contraceptive options should take place with the healthcare provider.

Summary:

The nurse’s discharge instructions for a client newly diagnosed with sickle cell anemia should focus on early recognition of sickle cell crisis symptoms (C), which is a key part of managing the condition and preventing complications. The other instructions about iron intake, hydroxyurea, and oral contraceptives should be individualized based on the client’s needs and medical history.

The correct answer is: Monitor spots for color change.

Explanation:

Monitor spots for color change:

This is the most important instruction because while most "age spots" (solar lentigines) are benign, any change in color, size, border, or shape may signal malignant transformation, such as progression to melanoma. The ABCDE rule (Asymmetry, Border irregularity, Color variation, Diameter >6 mm, Evolving) is a critical tool for assessing pigmented lesions. New or changing pigmentation—especially darkening, uneven coloration, or rapid growth—should be evaluated by a healthcare provider immediately.

Why the other options are wrong:

Limit the time you spend in the sun:

This is important for prevention of new age spots and UV-related damage, but it does not address the current concern, which is the development of new or changing spots. Prevention is valuable, but it’s not the priority if the client is already developing spots.

Monitor for signs of infection:

Infection is not a typical concern with age spots. They are usually flat, non-raised, and not associated with wounds or breaks in the skin, so the risk of infection is low unless the spot is bleeding or ulcerated, which again points to possible malignancy rather than infection.

Use skin cream to prevent drying:

Moisturizers are useful for comfort and managing general skin dryness in older adults, but they have no effect on preventing or monitoring age spots or skin cancer. This is general skincare advice, not specific or urgent in this context.

Summary:

The most important instruction is C. Monitor spots for color change, because color change is a key early warning sign of skin cancer. While sun exposure should be limited (A), and general skin care is helpful (D), the priority is early detection of potentially dangerous changes in pigmentation.