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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["0.8"]

Explanation

Calculation steps:

Step 1: Identify the dosage required. 4 mg

Step 2: Identify the concentration available. 5 mg/mL

Step 3: Calculate the volume to be administered. 4 mg ÷ 5 mg/mL Result: 0.8 mL

A. A client who is involuntarily admitted must take prescribed medications. B. An involuntary admission is justified if the client is a danger to themselves or others. C. An involuntary admission of a client is limited to two weeks. D. A client who is involuntarily admitted can leave the facility against medical advice.

Correct Answer is B

Explanation

Choice A reason: Clients who are involuntarily admitted still retain the right to refuse certain treatments, including medications, unless court-ordered.

Choice B reason: The correct answer is b) because involuntary admission is typically justified when a client poses a danger to themselves or others.

Choice C reason: The duration of involuntary admissions varies by jurisdiction and is not universally limited to two weeks.

Choice D reason: Clients who are involuntarily admitted cannot leave against medical advice until they are deemed safe to do so.

A newly admitted client states to the nurse, "You walk and talk just like my sister. She also gives me a headache." Which of the following is the client experiencing?

a) Suppression

b) Transference

c) Countertransference

d) Assertiveness

The correct answer is: b) Transference.

Choice A reason: Suppression involves consciously trying to forget or avoid thoughts, not projecting feelings onto another person.

Choice B reason: The correct answer is b) because transference occurs when a client projects feelings and attitudes from a past relationship onto a person in the present, such as a nurse.

Choice C reason: Countertransference refers to the nurse's emotional response to the client, not the client's feelings towards the nurse.

Choice D reason: Assertiveness is a communication style and is not related to projecting past feelings onto others.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer diazepam 4 mg IV bolus stat. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth.)

Correct Answer is ["0.8"]

Explanation

A nurse in an acute mental health facility is leading a nursing education session about the legal aspects of involuntary admissions. Which of the following pieces of information should the nurse include?

Correct Answer is B

Explanation

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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?