ATI Nur 211 Midpoint Assessment Exam

The correct answers are:

Fall prevention interventions

Encouraging increased fluid intake

Monitoring for constipation

Explanation

Fall prevention interventions

Severe hypercalcemia can cause muscle weakness, confusion, and decreased deep tendon reflexes, leading to an increased risk of falls. Implementing fall prevention measures, such as keeping the bed in a low position, assisting with ambulation, and ensuring a clutter-free environment, is essential.

Encouraging increased fluid intake

Hypercalcemia increases the risk of kidney stones and dehydration due to increased calcium excretion in the urine. Encouraging fluids (preferably 3-4 L/day unless contraindicated by heart or kidney disease) helps prevent stone formation and enhances calcium excretion through the kidneys.

Monitoring for constipation

High calcium levels slow down smooth muscle contractions, leading to decreased peristalsis and constipation. The nurse should monitor bowel movements and assess for abdominal distention or hypoactive bowel sounds.

Why the other options are incorrect:

Teaching regarding sodium

While sodium and calcium balance can be related (high sodium intake can promote calcium excretion), sodium education is not a primary nursing intervention for severe hypercalcemia.

 Explaining how to take daily weights

Daily weights are more relevant for fluid balance monitoring (e.g., heart failure or kidney disease). While hypercalcemia can cause fluid shifts, daily weight monitoring is not a primary intervention for treating hypercalcemia.

Summary:

The priority nursing interventions for severe hypercalcemia include fall prevention interventions due to muscle weakness and confusion, increased fluid intake to reduce kidney stone formation, and monitoring for constipation due to reduced peristalsis. Sodium education and daily weights are not primary interventions for this condition.

Correct Answer: “I will not have to use CPAP if I am prescribed protriptyline.”

Explanation:

“I will not have to use CPAP if I am prescribed protriptyline.”: This statement is incorrect and indicates the need for additional education. Protriptyline is a tricyclic antidepressant that is sometimes used in the treatment of sleep apnea, but it is not a substitute for continuous positive airway pressure (CPAP) therapy. CPAP remains the gold standard treatment for obstructive sleep apnea and helps maintain airway patency during sleep. Therefore, the client must continue using CPAP therapy as prescribed, even if other medications are added.

Why the other options are correct:

“If I lose weight, I may not need treatment for my sleep apnea.”: This statement is partially correct. Weight loss can help reduce the severity of obstructive sleep apnea in some individuals, and in certain cases, it may reduce or eliminate the need for CPAP therapy. However, this outcome is not guaranteed for everyone, and many individuals with obstructive sleep apnea will still require treatment even after weight loss. Therefore, while the statement suggests a positive change, it still reflects a realistic approach that doesn't negate the need for treatment.

“Taking modafinil will help reduce my sleepiness in the daytime.”: This statement is correct. Modafinil is a medication used to treat excessive daytime sleepiness in patients with obstructive sleep apnea who have failed to respond adequately to CPAP therapy. It is an adjunctive treatment aimed at improving daytime alertness and reducing sleepiness, but it does not replace the need for CPAP or other standard treatments for the disorder.

Summary:

The client’s statement about discontinuing CPAP therapy after taking protriptyline is incorrect and reflects a misunderstanding of treatment for obstructive sleep apnea. While weight loss and medications like modafinil may help manage symptoms, CPAP therapy remains a cornerstone treatment for most patients with obstructive sleep apnea.

Correct Answer: “This is a bacterial infection of the tissues that cover the brain and spinal cord.”

Explanation:

Bacterial meningitis is an infection of the meninges, which are the protective layers surrounding the brain and spinal cord. The most accurate response would explain that the condition involves a bacterial infection of the meningeal tissues. This response is straightforward, clear, and provides the mother with a correct understanding of what bacterial meningitis is.

Why the other choices are incorrect:

“There is bleeding into his brain causing irritation of the meninges.”

This statement is inaccurate for bacterial meningitis. Bleeding into the brain could indicate a hemorrhagic stroke or other forms of intracranial hemorrhage, not meningitis. Meningitis involves inflammation of the meninges due to infection, not bleeding.

 “Your child is experiencing inflammation of the brain due to a blockage of CSF drainage.”

This statement is not correct in describing bacterial meningitis. While blockage of CSF (cerebrospinal fluid) drainage can lead to conditions like hydrocephalus, it is not the primary cause of bacterial meningitis. Bacterial meningitis is specifically due to infection of the meninges, not an obstruction of CSF drainage.

 “This is an inflammation of the brain parenchyma caused by a mosquito bite.”

This statement describes encephalitis, which is an inflammation of the brain parenchyma (the functional tissue of the brain) and can sometimes be caused by viruses transmitted by mosquito bites. However, it does not accurately describe bacterial meningitis, which specifically involves meningeal inflammation due to bacterial infection.

Summary:

The most appropriate response is “This is a bacterial infection of the tissues that cover the brain and spinal cord.” bacterial meningitis is a bacterial infection of the meninges, the protective coverings of the brain and spinal cord. The other options describe different conditions, either inaccurately or related to other causes of brain or spinal cord inflammation.

Correct Answer: Head of the bed elevated 30 to 40 degrees with the neck in neutral alignment

Explanation:

After a craniotomy, it is crucial to maintain proper positioning to ensure optimal cerebral perfusion and to avoid increased intracranial pressure (ICP). Elevating the head of the bed to 30 to 40 degrees with the neck in neutral alignment helps in reducing the risk of ICP increase, promoting venous drainage, and ensuring the best circulation to the brain. Neutral alignment of the neck ensures that there is no compression of the jugular veins, preventing further elevation of ICP.

Why the other choices are incorrect:

 Lying flat on the back with no elevation

Lying flat increases the risk of elevated ICP due to impaired venous drainage from the brain. It does not facilitate optimal cerebral perfusion and could lead to complications such as edema or bleeding at the surgical site.

Turning the patient on their side to prevent aspiration

While turning the patient on their side may be necessary in some cases to prevent aspiration, this is not the recommended position for a post-craniotomy patient. Lateral positioning may compromise cerebral perfusion and is generally avoided unless there are specific respiratory concerns that require it.

Sitting upright in a chair for better breathing

Sitting upright may not be the most appropriate early postoperative positioning for a craniotomy. It may increase the risk of ICP elevation, particularly in the first 24-48 hours after surgery, as gravity may impede venous drainage from the brain.

Summary:

Post-craniotomy, the most appropriate position is to elevate the head of the bed to 30-40 degrees with the neck in neutral alignment. This helps reduce the risk of elevated ICP and supports optimal cerebral circulation, which is essential for recovery.

Correct Answers:

Loosening restrictive clothing

Removing the pillow and raising padded side rails

Positioning the client to the side, if possible, with the head flexed forward

Explanation:

When caring for a client who begins to experience a seizure, the primary goal is to prevent injury and maintain airway patency. The following actions are appropriate:

Loosening restrictive clothing: This allows for greater mobility and can help prevent any further injury, especially to the neck or chest area.

Removing the pillow and raising padded side rails: These actions are part of a seizure precaution protocol to reduce the risk of the client hitting their head against any hard surfaces, such as the bed's side rails or pillow. Padded side rails are used to protect the client from injury during the seizure.

Positioning the client to the side, if possible, with the head flexed forward: This position helps maintain an open airway and reduces the risk of aspiration in case the client vomits during the seizure. Positioning on the side allows for any secretions or fluids to drain from the mouth.

Why the other choices are incorrect:

Restraining the client's limbs: This is not appropriate during a seizure. Restraining the client's limbs can increase the risk of injury and cause harm. Instead, the nurse should allow the seizure to run its course and ensure that the area is clear of hazards.

Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist: While it's important to have access to the patient, closing the curtain can actually impede airflow, and the priority should be protecting the patient. It's also not as critical as ensuring the airway and safety of the client.

Correct Answer: Squeeze the nurse's hand

Explanation

Squeezing the nurse's hand is a common and effective method for assessing a patient's motor response in a neurological exam. This test evaluates the child's ability to follow a simple command and also checks the motor function of the upper extremities, which are often assessed in situations like head injuries to determine the level of consciousness and neurological integrity.

Explanation of Incorrect Answers:

Follow commands to wiggle his toes - While this is a valuable motor test for lower extremity function, in this scenario, the nurse is assessing the upper body. Since the child is more likely to have a better ability to follow simple commands involving the hands, squeezing the hand is a more appropriate choice for the initial evaluation. 

Lift his arms over his head - While lifting the arms can be part of a neurological assessment, this is a more complex task requiring strength and coordination, and may not be the best way to assess motor responses immediately after a head injury. 

Close his eyes tightly - This command evaluates facial nerve function rather than general motor responses. While useful in assessing cranial nerve function, it doesn't provide the same level of insight into the overall motor response that squeezing the hand does.

Summary:

When assessing a child with a potential head injury, squeezing the nurse's hand is a simple and effective way to evaluate both motor responses and the child's level of consciousness. It is an appropriate, straightforward command that can be performed easily and is key in assessing the child's neurological status following a head injury.

The correct answer is: Orthopnea

Explanation

Orthopnea:

This is correct. Orthopnea, which is difficulty breathing when lying flat, is a common symptom of heart failure, even in toddlers. In heart failure, the heart is unable to effectively pump blood, leading to fluid retention and congestion in the lungs. This makes it harder to breathe when the child is lying down, which is a characteristic of orthopnea.

Why the other options are wrong:

 Bradycardia:

Bradycardia (a slow heart rate) is not typically associated with heart failure in toddlers. Instead, tachycardia (an elevated heart rate) is more common as the heart works harder to compensate for reduced cardiac output. Bradycardia may occur in certain conditions but is not a typical finding in heart failure.

Weight loss:

Weight loss is not a typical finding in heart failure. Instead, heart failure usually leads to weight gain due to fluid retention, as the heart's inability to pump blood effectively results in fluid buildup in the body. Weight loss would more likely be seen in cases of severe malnutrition or chronic illness.

Increased urine output:

In heart failure, urine output is typically decreased rather than increased. The kidneys are affected by decreased blood flow, leading to fluid retention and reduced urine output. Increased urine output is more commonly seen with conditions such as diuretic therapy or diabetes insipidus, not heart failure.

Summary:

The nurse should expect to find orthopnea in a toddler with heart failure, as it is a result of fluid accumulation in the lungs and difficulty breathing when lying flat. Bradycardia, weight loss, and increased urine output are not typically associated with heart failure in toddlers.

Correct Answer: Marked irritability

Explanation

Marked irritability after a shunt procedure in a child is a serious concern. This behavior could be indicative of complications such as shunt malfunction, infection, or worsening intracranial pressure (ICP). The shunt is designed to drain excess cerebrospinal fluid (CSF) from the brain, and if it is not functioning properly, fluid may accumulate, increasing ICP. Symptoms of this condition include irritability, lethargy, vomiting, and headache, which should be immediately addressed to prevent further neurological deterioration.

Explanation

 Mild headache: Mild headaches after surgery are common and may occur due to the recovery process or minor post-operative discomfort. While headaches can be associated with increased ICP, a mild headache in isolation, without other signs of deteriorating condition, is not as concerning as irritability. It is typically not a cause for alarm unless accompanied by other symptoms.

Increased appetite: An increased appetite is generally a positive sign of recovery, particularly in children. It suggests that the child is beginning to feel better and may be returning to normal eating patterns. There is no immediate cause for concern regarding an increased appetite in this context.

 Slight fever: A slight fever can be a common post-operative finding due to mild inflammation. While fever could indicate infection, a mild fever without other critical signs (such as marked irritability, vomiting, or a significant change in neurological status) is typically not an immediate cause for concern. The nurse would continue to monitor the fever, but it does not indicate an urgent issue like irritability does.

Summary:

The most concerning finding is marked irritability, as it may signal shunt malfunction, infection, or worsening ICP. Mild headache, increased appetite, and slight fever are less concerning post-operative symptoms and do not indicate an immediate need for intervention. A nurse should closely monitor for signs of shunt malfunction or infection, including irritability, vomiting, and lethargy, which require urgent intervention to prevent further complications.

Correct Answer: Agraphia

Explanation:

Agraphia is the inability to write, which can occur after a stroke or brain injury. It is a condition where a person has difficulty writing words or symbols, even though they can understand what writing is and might still be able to speak or read. This is consistent with the patient's inability to sign the consent form due to the inability to write.

Why the other choices are incorrect:

Apraxia

Apraxia is a motor disorder where a person has difficulty planning and executing voluntary movements, despite having the physical ability to do so. In this case, the issue is specifically related to writing, so agraphia is the correct term. Apraxia would typically manifest as difficulty with tasks like brushing teeth or buttoning a shirt, not writing specifically.

Dysphasia

Dysphasia is a language disorder that affects speech comprehension or production. It is not related to the inability to write. Since the issue in this case is writing, agraphia is the correct term.

 Dysarthria

Dysarthria is a motor speech disorder that affects the muscles used for speaking, making speech slurred or difficult to understand. It does not directly relate to the inability to write, so this is not the correct term.

Summary:

The patient's inability to write or sign the consent form is consistent with agraphia, which is the loss of the ability to write, often caused by a stroke affecting the areas of the brain involved in written communication.