A patient diagnosed with a spinal cord injury experienced spinal shock lasting 15 days. The patient is now experiencing an uncompensated cardiovascular response to sympathetic stimulation. What does the nurse suspect caused this condition?
Pain stimulation above the level of the spinal cord lesion
Toxic accumulation of free radicals below the level of the injury
A distended bladder or rectum
An abnormal vagal response
The Correct Answer is C
Choice A reason: Pain stimulation above the level of the spinal cord lesion can cause discomfort and an increase in sympathetic activity, but it is not the primary cause of an uncompensated cardiovascular response seen in autonomic dysreflexia. This condition typically results from stimuli below the level of the injury.
Choice B reason: Toxic accumulation of free radicals below the level of the injury can contribute to tissue damage and inflammation but is not the primary cause of the acute cardiovascular responses in autonomic dysreflexia. The condition is primarily triggered by noxious stimuli below the level of the injury.
Choice C reason: A distended bladder or rectum is a common cause of autonomic dysreflexia in patients with spinal cord injuries above the T6 level. This condition involves an exaggerated autonomic response to stimuli below the level of the injury, resulting in severe hypertension, bradycardia, and other cardiovascular symptoms. The distention of the bladder or rectum sends signals that the spinal cord cannot properly process, leading to an uncontrolled sympathetic response.
Choice D reason: An abnormal vagal response typically involves parasympathetic activity and can lead to symptoms such as bradycardia or fainting. However, it is not the primary cause of the sympathetic overactivity and hypertension seen in autonomic dysreflexia. The condition is driven by an imbalance in the autonomic nervous system due to spinal cord injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Compensated metabolic acidosis is characterized by a low pH (acidemia) with a compensatory decrease in PaCO2 due to hyperventilation, and typically a low HCO3 as well. In this scenario, the pH is elevated (alkalemia), which rules out metabolic acidosis.
Choice B reason: Compensated metabolic alkalosis is characterized by a high pH (alkalemia) with a compensatory increase in PaCO2 due to hypoventilation, and a high HCO3. In this case, the PaCO2 is low rather than high, and the HCO3 is within the normal range, which rules out metabolic alkalosis.
Choice C reason: Respiratory alkalosis is characterized by a high pH (alkalemia) and a low PaCO2, indicating that the alkalosis is due to excessive loss of CO2 through hyperventilation. The HCO3 is usually normal or slightly decreased as a compensatory mechanism. The provided ABG values (pH = 7.53, PaCO2 = 23, HCO3 = 22) are consistent with respiratory alkalosis, where the elevated pH and low PaCO2 point towards hyperventilation as the cause of the alkalemia.
Choice D reason: Uncompensated respiratory alkalosis would present with a high pH and low PaCO2, without significant compensation by the kidneys (i.e., HCO3 would still be normal). In this scenario, the ABG values fit the description of respiratory alkalosis, but it is considered compensated since the HCO3 is within the normal range, indicating some level of renal compensation.
Correct Answer is B
Explanation
Choice A reason: Bronchoconstriction refers to the narrowing of the airways in the lungs due to the contraction of the surrounding smooth muscle. This condition is typically associated with asthma or allergic reactions and is not directly related to Virchow's triad, which concerns factors leading to thrombosis (formation of blood clots).
Choice B reason: Pulmonary embolus is a blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel to the lungs from the legs or other parts of the body (deep vein thrombosis). Virchow's triad describes the three primary factors that predispose individuals to thrombosis: hypercoagulability (increased tendency of blood to clot), stasis of blood flow, and endothelial injury (damage to the blood vessel wall). These factors contribute to the formation of blood clots, which can ultimately result in a pulmonary embolus if they dislodge and travel to the lungs.
Choice C reason: Decreased pulmonary arterial pressure is not a consequence of the factors described in Virchow's triad. In fact, a pulmonary embolus can lead to increased pulmonary arterial pressure due to the obstruction of blood flow in the pulmonary arteries, which can strain the right side of the heart and lead to complications.
Choice D reason: Alveolar collapse, also known as atelectasis, occurs when the tiny air sacs in the lungs (alveoli) deflate or fill with fluid. This condition is typically due to reasons such as airway obstruction, surfactant deficiency, or lung compression, and is not directly related to the formation of blood clots described by Virchow's triad.
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