A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?
Hypotension and venous pooling in the extremities.
Pain and a burning sensation upon urination and hematuria.
Profuse diaphoresis and severe, pounding headache.
Reports of chest pain and shortness of breath.
The Correct Answer is C
Choice A reason: Hypotension and venous pooling in the extremities are not typical of autonomic dysreflexia. Autonomic dysreflexia usually results in hypertension due to an exaggerated autonomic response to a stimulus such as a full bladder. This condition is characterized by severe, uncontrolled hypertension rather than hypotension.
Choice B reason: While pain and a burning sensation upon urination and hematuria can be related to a urinary tract infection or bladder issue, they are not specific to autonomic dysreflexia. Autonomic dysreflexia presents with symptoms that result from the body's exaggerated response to the stimulus, such as severe headache and sweating.
Choice C reason: The correct answer is c) because profuse diaphoresis (sweating) and a severe, pounding headache are hallmark signs of autonomic dysreflexia. This condition occurs in individuals with spinal cord injuries at or above the T6 level and is triggered by stimuli like a full bladder, causing a dangerous rise in blood pressure and severe autonomic responses.
Choice D reason: Reports of chest pain and shortness of breath are not typical signs of autonomic dysreflexia. While these symptoms may be concerning, they are not the primary indicators of this specific condition. The severe headache and sweating are more indicative of autonomic dysreflexia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A strong professional relationship does not involve personal plans outside of the therapeutic context.
Choice B reason: Countertransference refers to the nurse's emotional response to the client, not planning personal activities together.
Choice C reason: Successful relationship building occurs within professional boundaries and does not involve personal plans.
Choice D reason: The correct answer is d) because making personal plans with a client blurs the boundaries of the professional therapeutic relationship, which can affect the nurse's objectivity and professionalism.
Correct Answer is ["750"]
Explanation
Calculation steps:
Step 1: Determine the total volume to be infused. 1500 mL
Step 2: Determine the time for infusion. 2 hours
Step 3: Calculate the rate in mL/h. 1500 mL ÷ 2 hours Result: 750 mL/h
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
