ATI Nur 211 Midpoint Assessment Exam

Correct Answers:

Flaccid Paralysis

Reflexes Damaged

Explanation:

Flaccid Paralysis

A spinal cord injury above T12 often leads to flaccid paralysis initially, especially in the immediate period after the injury. This is because the spinal cord's ability to communicate with the muscles below the level of the injury is disrupted, resulting in no voluntary movement or flaccid muscle tone. This is typically seen during the shock phase of the injury.

Reflexes Damaged

At or above the T12 level, the spinal cord injury can result in damage to the reflex arcs, especially during the acute phase. Reflexes may not function properly in the initial period after the injury, as the spinal cord is unable to properly transmit signals. Reflexes might not be intact immediately, especially if the injury is severe enough to cause damage to the reflex pathways. However, over time, as the patient moves out of the spinal shock phase, reflexes may return, but they could be abnormal (spastic or exaggerated)

Why the other choices are incorrect:

Reflexes Intact

In the acute phase following an injury above T12, reflexes are often not intact and may be damaged or absent due to spinal shock. Reflexes can become exaggerated (spastic) later on after the patient recovers from spinal shock.

Spastic Paralysis

Spastic paralysis tends to develop after the spinal shock phase in patients with upper motor neuron injuries, typically occurring after injuries at or above the T12 level. However, initially, the paralysis is flaccid, and spasticity usually develops later as the injury progresses beyond the immediate acute phase.

Summary:

For a spinal cord injury above T12, patients will likely exhibit flaccid paralysis in the immediate period following the injury, and reflexes may be damaged or absent initially. Spastic paralysis may develop later as the patient recovers from spinal shock.

Correct Answer:

Cigarette smoking

Familial predisposition

Inadequate intake of dietary calcium

Explanation:

Several factors contribute to the development of osteoporosis in female clients:

 Cigarette smoking: Smoking is a significant risk factor for osteoporosis. It accelerates bone loss by reducing the blood supply to the bones and decreases calcium absorption. It also reduces estrogen levels, which are critical for maintaining bone density, especially in postmenopausal women.

Familial predisposition: Osteoporosis can run in families, so having a family history of the disease increases the risk. Genetics plays a significant role in bone density, and those with a family history of osteoporosis are more likely to develop it themselves.

Inadequate intake of dietary calcium: Calcium is vital for bone health. Insufficient calcium intake can lead to weakened bones and increase the risk of osteoporosis. Calcium is necessary for bone formation and maintaining bone density, particularly in women post-menopause.

Why the other options are incorrect:

Moderate exercise: Moderate exercise, particularly weight-bearing and strength-training exercises, is actually beneficial for bone health. It helps maintain bone density and strength, thus reducing the risk of osteoporosis. So, moderate exercise does not contribute to osteoporosis development.

 Use of street drugs: While the use of street drugs can have detrimental effects on overall health, it is not a direct risk factor for osteoporosis. However, certain drugs such as corticosteroids and some other medications can increase the risk of osteoporosis, but street drugs are not typically mentioned as a direct cause.

Summary:

Factors contributing to the development of osteoporosis in female clients include cigarette smoking, familial predisposition, and inadequate intake of dietary calcium. Moderate exercise is beneficial for bone health, and while the use of street drugs can harm overall health, it is not a primary factor for developing osteoporosis.

Correct Answer: 90 mmHg, normal

Explanation:

To calculate cerebral perfusion pressure (CPP), the following formula is used:

CPP = MAP - ICP

Where MAP (mean arterial pressure) is calculated as:

MAP = (SBP + 2 * DBP) / 3

SBP = systolic blood pressure

DBP = diastolic blood pressure

For the given blood pressure of 130/88 mmHg,

MAP = (130 + 2 * 88) / 3 = (130 + 176) / 3 = 306 / 3 = 102 mmHg

Now, calculate CPP:

CPP = MAP - ICP = 102 - 12 = 90 mmHg

A CPP of 90 mmHg is within the normal range (typically 60-100 mmHg), indicating adequate cerebral perfusion. This is a favorable sign for the patient, as it suggests the brain is receiving sufficient blood flow and oxygenation.

Why the other choices are incorrect:

110 mmHg, high

A CPP of 110 mmHg would be considered high, which can be a result of excessive blood flow, possibly increasing intracranial pressure or leading to complications.

75 mmHg, low

A CPP of 75 mmHg would be considered low and may suggest that the brain is not being adequately perfused, which can lead to ischemia and damage to brain tissue.

95 mmHg, normal

While a CPP of 95 mmHg is within the normal range, the correct answer here is 90 mmHg based on the given information.

Summary:

The patient's cerebral perfusion pressure (CPP) is 90 mmHg, which is within the normal range, indicating that the brain is receiving adequate blood flow and perfusion. This is a positive sign for maintaining brain health in the context of the patient's ICP reading of 12 mmHg

The correct answer is: Atrial fibrillation

Explanation

Atrial fibrillation (AFib) is characterized by an irregular rhythm with an unidentifiable P wave and an unmeasurable PR interval. The heart rate can vary, and the QRS duration remains within normal limits (as seen in this case). In AFib, the atria do not contract in a coordinated fashion, leading to an irregular rhythm and the absence of distinct P waves on the ECG strip.

Why the other options are wrong:

First-degree heart block:

This is incorrect. In first-degree heart block, the rhythm is typically regular, and the P waves are identifiable. There is a prolonged PR interval (>0.20 seconds), but the P waves are still present and measurable. The absence of P waves and the inability to measure the PR interval rule out this diagnosis.

 Supraventricular tachycardia (SVT):

SVT usually presents with a regular rhythm and a rapid heart rate, often >150 bpm. The P waves may be difficult to distinguish, but they are still present and identifiable. In this case, the heart rate of 92/min is not consistent with the high rate typically seen in SVT.

Sinus bradycardia:

 Sinus bradycardia would have a regular rhythm with identifiable P waves and a measurable PR interval, with a heart rate typically less than 60 bpm. The irregular rhythm and unidentifiable P waves make this diagnosis unlikely.

Summary:

The irregular rhythm with unidentifiable P waves and an unmeasurable PR interval is characteristic of atrial fibrillation, a condition where the atria quiver rather than contract effectively. The other options either describe conditions with regular rhythms or identifiable P waves.

Correct Answer: Bradycardia and hypertension

Explanation:

Bradycardia and hypertension

Autonomic dysreflexia is a life-threatening condition that occurs primarily in patients with spinal cord injuries at or above the T6 level. It is characterized by an exaggerated sympathetic response to stimuli below the level of injury. This leads to severe hypertension (high blood pressure) and bradycardia (slow heart rate). The hypertension is caused by vasoconstriction below the level of injury, while the bradycardia is a compensatory parasympathetic response. This condition requires immediate treatment, typically by removing the triggering stimulus (such as a full bladder or bowel impaction).

Why the other choices are incorrect:

 Respiratory distress and projectile vomiting

While respiratory distress can occur in critically ill patients, projectile vomiting is not a hallmark symptom of autonomic dysreflexia. Respiratory issues might arise from other causes, such as pulmonary complications or aspiration. This symptom complex is not specific to autonomic dysreflexia.

 Tachycardia and agitation

While tachycardia (fast heart rate) and agitation may be seen in other conditions, tachycardia is not typically present in autonomic dysreflexia, where the primary issue is bradycardia. Agitation may occur as a result of discomfort or distress, but it is not one of the primary clinical manifestations of this condition.

Third-spacing and hyperthermia

Third-spacing refers to the abnormal accumulation of fluid in the extracellular space, often in conditions like sepsis or trauma. Hyperthermia is an elevated body temperature that can occur in certain conditions but is not a characteristic feature of autonomic dysreflexia. These symptoms are not directly related to this condition.

Summary:

The correct clinical manifestations of autonomic dysreflexia include bradycardia and hypertension, which occur due to an overactive sympathetic nervous system response to a noxious stimulus below the level of spinal cord injury. Other symptoms like tachycardia, respiratory distress, and third-spacing are not specific to this condition.

Correct Answer: The exchange transfusion is used to quickly replace sickled hemoglobin with normal hemoglobin, improving oxygenation and reducing complications like stroke and acute chest syndrome.

Explanation:

Exchange transfusion is an advanced treatment used in emergency situations like acute chest syndrome or stroke in sickle cell disease. During an exchange transfusion, sickled red blood cells are removed from the patient's circulation and replaced with healthy donor red blood cells. This procedure rapidly reduces the proportion of sickled hemoglobin in the blood, which improves oxygenation and reduces the complications associated with sickle cell disease, such as ischemia, stroke, and acute chest syndrome. This procedure is particularly important because it addresses the root cause of these emergencies: the sickled red blood cells that obstruct blood flow and reduce oxygen delivery to vital organs.

Why the other options are incorrect:

 The exchange transfusion will provide immediate pain relief and prevent further sickling of red blood cells. – While pain relief is an important aspect of sickle cell management, exchange transfusion is not directly used for pain management. Its purpose is to reduce the number of sickled cells and improve oxygenation, which can ultimately reduce pain in the long term, but it is not an immediate pain relief measure.

The exchange transfusion is primarily used to remove iron buildup from the blood, reducing the risk of organ damage. – While iron buildup is a concern in chronic blood transfusions, exchange transfusion in the context of acute sickle cell complications (such as acute chest syndrome or stroke) is not primarily focused on iron removal. Its main purpose is to replace sickled hemoglobin with normal red blood cells to improve oxygen delivery and reduce the risk of further complications.

The exchange transfusion prevents dehydration and balances the electrolyte levels, helping in pain management. – Dehydration and electrolyte imbalances are concerns in sickle cell disease, but exchange transfusion is not primarily used to treat these issues. The goal of the procedure is to address the sickling of red blood cells and the complications arising from these cells, such as blockages in blood flow and oxygen delivery.

Summary:

In the management of acute complications like acute chest syndrome and stroke, exchange transfusion is an emergency treatment aimed at replacing sickled hemoglobin with normal hemoglobin, thus improving oxygenation and reducing the risk of further damage to vital organs. It does not primarily address pain relief, iron buildup, or electrolyte imbalances, although it may help in reducing long-term complications associated with sickle cell disease.

Correct Answer: Administering IV phosphate supplements

Explanation:

The patient's symptoms are indicative of hypophosphatemia, which can present with tremors, hyperreflexia, paresthesia, confusion, muscle weakness, anorexia, dysphagia, and decreased oxygen saturation. Hypophosphatemia often results from malnutrition, chronic alcoholism, or certain infections, and it can severely impact cellular function. The primary treatment for hypophosphatemia is the administration of phosphate supplements, either orally or intravenously, to correct the deficiency. This helps restore normal cell function, including muscle and respiratory function, and prevents further complications such as respiratory failure or seizures.

Why the other options are incorrect:

 Increasing the patient's fluid intake

While fluid balance is essential, increasing fluid intake alone would not address the underlying hypophosphatemia or help manage the symptoms like muscle weakness and confusion. The priority is correcting the phosphate deficiency.

Encouraging the patient to eat high-protein foods

Although adequate nutrition is important, high-protein foods alone are unlikely to correct hypophosphatemia. Protein intake does not directly replenish phosphate levels, and this approach would not be effective in addressing the patient's symptoms.

Providing a sedative to manage confusion

Sedatives should not be the first-line intervention for confusion, especially in a patient who has signs of hypophosphatemia. The confusion is likely related to the electrolyte imbalance, and the priority is to correct the phosphate deficiency. Administering a sedative could worsen the patient's respiratory function or delay the identification and treatment of the underlying cause.

Summary:

The patient is displaying classic signs of hypophosphatemia, and the most appropriate intervention is the administration of IV phosphate supplements to correct the deficiency and prevent further complications.

Correct Answer: A cerebrospinal infection

Explanation:

Meningitis is an infection of the protective membranes (meninges) surrounding the brain and spinal cord, which are filled with cerebrospinal fluid (CSF). This infection causes inflammation and can affect both the brain and spinal cord, leading to serious symptoms and complications. Cerebrospinal fluid serves as the medium where the infection can spread, making meningitis a cerebrospinal infection. A cerebrospinal infection is the correct description. Meningitis is caused by an infection of the meninges, which are the protective membranes that cover the brain and spinal cord. The infection may result from bacteria, viruses, fungi, or parasites, and it involves the cerebrospinal fluid, which is where the inflammation occurs.

Why the Other Options Are Incorrect:

A viral infection of the brain:

While viral meningitis is a type of meningitis caused by viruses, the term meningitis refers to the infection of the meninges, not the brain itself. The brain can be affected in some cases of meningitis, but it is not the primary focus. Therefore, this answer is not a complete or accurate description of meningitis.

A condition caused by a stroke:

Meningitis is unrelated to strokes. A stroke occurs when there is a disruption in blood flow to the brain, leading to brain tissue damage. Meningitis, on the other hand, is an infection of the meninges, not caused by any problems with blood flow to the brain. This makes this answer incorrect.

A neurological disease affecting the spinal cord:

While meningitis can affect both the brain and spinal cord, it is not specifically a neurological disease of the spinal cord. Meningitis affects the meninges (the covering of the brain and spinal cord), not the spinal cord tissue itself.

Summary:

Meningitis is an infection of the meninges, the protective layers around the brain and spinal cord. The infection can be caused by various pathogens, including bacteria and viruses, and is characterized by inflammation in the cerebrospinal fluid. Thus, the most accurate description of meningitis is that it is a cerebrospinal infection.

The correct answer is: Morphine

Explanation 

Morphine is commonly administered to clients with acute myocardial infarction (MI) after the initial phase to help manage pain and anxiety. It works by providing pain relief and also reducing anxiety, which can help lower the heart's workload and reduce oxygen demand. Additionally, morphine has vasodilatory properties that can help alleviate the stress on the heart during an MI.

Why the other options are wrong:

Oxygen:

Oxygen is typically administered in the initial acute phase of an MI if the client is hypoxic. However, after the initial stabilization, oxygen is not generally used to manage pain and anxiety. It’s used primarily to ensure adequate oxygenation during the acute event.

Nitroglycerin:

Nitroglycerin is often used during the acute phase of an MI to relieve chest pain by dilating the coronary arteries. However, after the acute phase, it may not be as appropriate for managing pain and anxiety unless there are ongoing ischemic symptoms. Nitroglycerin is typically avoided if the patient has hypotension or is hemodynamically unstable.

 Aspirin:

Aspirin is an antiplatelet medication used early in the treatment of an MI to prevent further clot formation, but it does not address pain or anxiety. It is not a pain management option.

Summary:

To manage pain and anxiety after the initial acute phase of an MI, the nurse should administer morphine, as it provides both analgesia and anxiety relief. Oxygen, nitroglycerin, and aspirin are critical for managing other aspects of the acute phase but are not primarily used for pain and anxiety management in the later stages.