ATI NUR 211 Final Assessment Fall Exam

Correct Answer:

WBC count

Respiratory rate

Skin assessment

Oxygen saturation

Breath sounds

Explanation of the Correct Answer:

WBC count of 15,000/mm³ – This WBC count is elevated above the normal range (5,000–10,000/mm³), indicating the potential for an infection or an exacerbation of leukemia. Since the child has leukemia and is experiencing symptoms like fever and respiratory distress, this is an important finding that should be reported to the provider promptly.

Respiratory rate of 30/min – An increased respiratory rate (normal is typically 18–24/min for school-age children) can indicate respiratory distress, especially in the context of the child’s complaint of not being able to breathe. This warrants immediate attention by the provider to assess the child’s respiratory status more thoroughly.

Skin assessment (petechiae noted on trunk and thighs) – Petechiae, especially in a child with leukemia, should be reported as it could indicate a platelet deficiency, which is a common complication in leukemia and its treatment. The presence of petechiae could suggest a worsening condition, such as thrombocytopenia, that requires intervention.

Oxygen saturation of 92% on room air – Oxygen saturation of 92% is lower than the normal range (95–100%) and suggests the child is experiencing hypoxia. This requires immediate attention to ensure the child’s respiratory needs are met and to prevent further complications.

Breath sounds clear with subcostal retractions – Although the breath sounds are described as clear, the presence of subcostal retractions indicates that the child is working harder to breathe, which is a sign of respiratory distress. This should be reported to the provider for further evaluation.

Retractions – Retractions are a sign of respiratory distress, indicating that the child is struggling to breathe. This is a critical finding that should be reported to the provider immediately, as it suggests the child may be developing respiratory failure or a need for more intensive respiratory support.

Explanation of Why the Other Options Are Incorrect:

Hemoglobin of 10 g/dL – While this hemoglobin level is on the low end of the normal range (10–15.5 g/dL), it is not an acute concern compared to the other findings. In the context of leukemia, mild anemia is common, and this level does not require immediate reporting unless the child is experiencing symptoms of severe anemia, which is not described here.

Upper respiratory infection – The child has a history of an upper respiratory infection for the last 2 months that won't resolve. However, given the child’s leukemia, this ongoing infection could be expected. It is important to monitor but does not need to be immediately reported unless it worsens or is associated with more severe complications, such as sepsis or respiratory failure.

Summary:

​​​​​​​The nurse should prioritize reporting findings such as an elevated WBC count, increased respiratory rate, petechiae, low oxygen saturation, and signs of respiratory distress (including retractions and abnormal breath sounds). These findings suggest that the child’s condition may be worsening or that new complications related to leukemia or infection are developing. The hemoglobin level and the ongoing upper respiratory infection are less urgent in comparison.

Correct Answer: 1 cup canned black beans

Explanation of the Correct Answer:

1 cup canned black beans

Black beans are an excellent source of non-heme iron, which is especially beneficial for clients with iron deficiency anemia. Iron from plant-based sources, like beans, is an important part of the diet to help increase iron levels in the body. Additionally, black beans provide other nutrients such as protein, fiber, and folate. While vitamin C enhances the absorption of non-heme iron, black beans can still be a very helpful food choice for someone with iron deficiency anemia.

Explanation of Why the Other Options Are Incorrect:

8 oz black tea

Black tea contains tannins, which can inhibit the absorption of iron from plant-based sources. Consuming tea with meals can decrease the effectiveness of iron absorption and is generally not recommended when someone is trying to increase iron levels.

1.5 oz raisins

While raisins do contain iron, they are not as rich in iron as black beans. Raisins provide a smaller amount of iron compared to other iron-rich foods, like legumes, which makes black beans a better choice for addressing iron deficiency anemia.

8 oz whole milk

Whole milk is not a significant source of iron and contains calcium, which can interfere with the absorption of iron. Consuming milk with meals can reduce the body's ability to absorb iron from plant-based sources.

Summary:

The nurse should recommend canned black beans (D) as they are a rich source of non-heme iron and other nutrients that can help address iron deficiency anemia. The other options either contain substances that hinder iron absorption (like black tea and milk) or do not provide as much iron as black beans.

Correct Answer:  Prostate cancer mortality is more than double for Black American males than for men in every other group.

Explanation of the Correct Answer:

Prostate cancer mortality is more than double for Black American males than for men in every other group – This is an important and well-documented public health consideration. Black American males are at significantly higher risk for both developing and dying from prostate cancer compared to men of other racial and ethnic groups. This disparity is attributed to a complex mix of factors including genetics, access to healthcare, socioeconomic status, and possible differences in tumor biology. When creating a screening plan for high-risk populations, it is essential to include targeted outreach, education, and earlier/more frequent screening for Black men, typically beginning at age 45 or earlier if there is a family history.

Explanation of Why the Other Options Are Incorrect:

Occupational toxin exposure among factory workers increases rates of prostate cancer by 30%. – While exposure to certain chemicals may increase cancer risk in general, there is no strong or consistent evidence showing that occupational toxin exposure in factory workers increases prostate cancer risk by 30%. This statistic is not validated by major health organizations and therefore should not be the basis for screening recommendations in high-risk populations.

The best way to determine prostate cancer risk is to have a computed tomography (CT) scan. – This is incorrect. CT scans are not the primary tool used for screening or risk determination for prostate cancer. The standard methods include the prostate-specific antigen (PSA) blood test and digital rectal exam (DRE). CT scans may be used later in the staging process after diagnosis to determine the spread of cancer but are not a first-line screening tool.

Dietary factors can increase the risk of prostate cancer mortality by as much as 50%. – While dietary habits (such as high intake of red meat and dairy, or low intake of fruits and vegetables) can influence prostate cancer risk, the claim of a 50% increase in mortality is exaggerated and unsupported by consistent evidence. Dietary factors are just one part of a multifactorial risk profile and should not be overstated in public health planning without robust data.

Summary:

The correct answer is D, as prostate cancer has a markedly higher mortality rate among Black American males, making it a critical factor when planning screening initiatives for high-risk groups. Options A, B, and C contain either inaccurate or unsubstantiated claims and do not represent priority considerations in evidence-based care planning

The correct answers are: 

Dehydration,

Extreme stress

High altitudes

Explanation:

Clients with sickle cell disease (SCD) should be taught self-management strategies to prevent exacerbations and reduce the risk of sickle cell crisis. Crisis episodes are usually triggered by factors that cause hypoxia, dehydration, acidosis, or increased metabolic demand, all of which promote sickling of red blood cells and vascular occlusion.

Dehydration – Correct

Dehydration reduces plasma volume and increases blood viscosity, making sickling and vaso-occlusion more likely. Clients must be instructed to stay well-hydrated at all times, especially during illness, heat, or physical exertion.

Extreme stress – Correct

Severe physical or emotional stress increases the body's metabolic demand and catecholamine release, which can trigger sickling. Stress reduction techniques and mental health support are important parts of SCD management.

High altitudes – Correct

At high altitudes, oxygen levels are lower, which increases the risk of hypoxia and red blood cell sickling. Clients with SCD are advised to avoid high altitudes or use supplemental oxygen if exposure is unavoidable.

Why other options are wrong

Exercise – Incorrect

Moderate exercise is generally safe and can be beneficial for overall health in clients with SCD. However, strenuous or prolonged activity that leads to dehydration or hypoxia should be avoided. Blanket avoidance of all exercise is not appropriate; the focus should be on hydration and avoiding overexertion, not exercise itself.

Pregnancy – Incorrect

Pregnancy is not a modifiable factor and should not be presented as something to “avoid” in teaching. While pregnancy in women with SCD carries increased risk and requires close monitoring by high-risk obstetric care, it is not a behavioral trigger like dehydration or stress. Women with SCD can have pregnancies with proper management and multidisciplinary support.

Summary:

To prevent sickle cell crises, clients should avoid dehydration, extreme stress, and high altitudes, all of which contribute to hypoxia or increased sickling risk. Exercise is not categorically contraindicated, and while pregnancy carries increased risks, it is not an avoidable behavioral trigger and should be addressed with appropriate prenatal care, not as a prevention strategy.

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 : 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.

The correct answer is : Internal insulin pump

Explanation:

A magnetic resonance imaging (MRI) procedure uses powerful magnets, which can interfere with certain electronic devices in the body, including an internal insulin pump. The strong magnetic field generated by the MRI can cause the insulin pump to malfunction or even be dislodged, posing serious health risks to the client, such as the inability to regulate blood sugar levels properly. Therefore, it is essential for the nurse to contact the provider and cancel the MRI if the client has an internal insulin pump.

Why the other options are incorrect:

Creatine phosphokinase of 100

A creatine phosphokinase (CPK) level of 100 is not a critical value and does not contraindicate an MRI. Elevated CPK can be related to muscle damage or other conditions, but it does not present an immediate risk for the MRI procedure.

Atrioventricular (AV) graft

While an AV graft involves a vascular procedure, it is not a contraindication to MRI unless there are specific components like a metal implant that could interact with the MRI's magnetic field. If the graft itself doesn't contain any metal or MRI-sensitive material, it does not typically interfere with the MRI procedure.

BUN of 50

A BUN (blood urea nitrogen) level of 50 is elevated, indicating possible renal dysfunction, but it does not directly contraindicate an MRI. While elevated BUN levels should be addressed for overall kidney health, this condition does not interfere with the MRI procedure itself.

Summary:

The presence of an internal insulin pump is the condition that requires contacting the provider and potentially canceling the MRI, as the magnetic field could interfere with the function of the pump and pose a serious risk to the client. The other conditions listed do not directly affect the safety of the MRI procedure.

The correct answer is : Notify the practitioner because chest syndrome is suspected

Explanation:

The symptoms described—severe chest pain, back pain, fever, cough, and dyspnea—are indicative of acute chest syndrome (ACS), a life-threatening complication of sickle cell anemia. ACS occurs when sickled red blood cells block blood flow to the lungs, leading to hypoxia, inflammation, and possibly pneumonia. It is a medical emergency and requires immediate intervention to prevent respiratory failure and other complications.

The first action should be to notify the practitioner because ACS must be diagnosed and treated promptly. Immediate medical evaluation, including chest imaging and blood tests, will be necessary to confirm the diagnosis and begin appropriate treatment, which may include oxygen therapy, antibiotics, and possibly blood transfusions.

Why the other options are wrong:

Administer 100% oxygen to relieve hypoxia

While administering oxygen may be part of the management plan for ACS (if hypoxia is confirmed), the first step is to notify the provider. The nurse cannot initiate oxygen therapy until a provider has been consulted and the situation is properly assessed. Additionally, oxygen alone will not address the underlying cause of the chest pain and other symptoms.

Infuse intravenous antibiotics as soon as cultures are obtained

Although antibiotics may be necessary if there is an underlying infection contributing to the chest symptoms (e.g., pneumonia), the first action is to notify the provider and confirm the diagnosis of ACS. Starting antibiotics without confirmation of infection may not address the primary issue (ACS), and it could delay other necessary interventions.

Give ordered pain medication to relieve symptoms of pain episode

While pain management is important for sickle cell crises, the first priority in this case is to assess for acute chest syndrome, which requires urgent attention. Pain medication alone will not address the potentially life-threatening complication of ACS. Pain management should be part of the overall treatment plan once the critical diagnosis is confirmed.

Summary:

The first action for a child with sickle cell anemia showing signs of acute chest syndrome is to notify the practitioner for prompt evaluation and treatment. This condition can lead to serious complications and requires immediate medical intervention. Administering oxygen, starting antibiotics, and giving pain medications are important, but they should occur after the provider is notified and the diagnosis is confirmed.

The correct answer is: Bilateral hypoactive reflexes

Explanation:

Long-standing diabetes mellitus can lead to diabetic peripheral neuropathy, a common complication characterized by nerve damage, especially in the lower extremities. This damage affects both sensory and motor nerves, resulting in reduced or absent deep tendon reflexes, particularly at the ankles. The nurse would expect to observe bilaterally diminished or hypoactive reflex responses, most often in the Achilles tendon. This is a typical clinical sign of chronic peripheral nerve impairment due to prolonged hyperglycemia.

Why the other options are wrong:

Bilateral hyperactive reflexes:

Hyperactive reflexes are typically associated with upper motor neuron lesions, such as those found in spinal cord injury, stroke, or multiple sclerosis. These are not characteristic of peripheral neuropathy from diabetes, which is a lower motor neuron condition.

Asymmetric reflex response:

An asymmetric response may suggest focal nerve injury or unilateral neurologic involvement such as radiculopathy or localized trauma. Diabetic peripheral neuropathy generally causes symmetrical deficits because it affects nerves in a diffuse, systemic manner.

Bilateral ankle clonus:

Clonus is a rhythmic, involuntary contraction typically associated with central nervous system pathology, particularly upper motor neuron lesions. It is not a typical finding in diabetic neuropathy, which involves peripheral nerves and does not produce clonus.

Summary:

In clients with long-standing diabetes mellitus, bilateral hypoactive deep tendon reflexes (A) are expected due to diabetic peripheral neuropathy. The condition causes symmetrical nerve damage that diminishes the normal reflex arc. Other options reflect upper motor neuron involvement or focal findings not consistent with diabetic complications.