A client who had a C5 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
Reports of chest pain and shortness of breath
Pain and a burning sensation upon urination and hematuria
Profuse diaphoresis and severe, pounding headache
The Correct Answer is D
Choice A reason: Hypotension and venous pooling in the extremities are typically signs of neurogenic shock, which occurs immediately after a spinal cord injury. However, autonomic dysreflexia is characterized by severe hypertension, not hypotension. The symptoms in this scenario do not fit the presentation of autonomic dysreflexia.
Choice B reason: Reports of chest pain and shortness of breath are not the primary symptoms of autonomic dysreflexia. While autonomic dysreflexia can cause a variety of symptoms due to uncontrolled sympathetic nervous system activity, the hallmark symptoms are severe hypertension and headache, along with other specific signs like diaphoresis.
Choice C reason: Pain and a burning sensation upon urination and hematuria indicate a urinary tract infection or another urological issue, not autonomic dysreflexia. While a full bladder is a common trigger for autonomic dysreflexia, the symptoms described in this choice do not accurately reflect the condition.
Choice D reason: Profuse diaphoresis and a severe, pounding headache are classic symptoms of autonomic dysreflexia. This condition results from an overactive autonomic nervous system response to stimuli below the level of the injury, such as a full bladder. The resulting vasoconstriction leads to severe hypertension and symptoms like headache and sweating above the level of injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","G"]
Explanation
Choice A reason:
Infection prevention is crucial in managing appendicitis. Administering preoperative antibiotics, such as cefazolin, helps prevent surgical site infections and other complications. This aligns with standard care protocols for appendicitis patients.
Choice B reason:
Relieving acute pain is a priority in appendicitis care. Administering analgesics, including opioids, acetaminophen, and NSAIDs, effectively manages pain and reduces inflammation. Providing distraction techniques can also help alleviate discomfort until pain relief is achieved.
Choice C reason:
Client education about the diagnosis and plan of care is essential. Informing the patient about appendicitis, the surgical procedure, and postoperative expectations reduces anxiety and promotes cooperation. Effective communication enhances patient outcomes and satisfaction.
Choice D reason:
Effective coping with illness-related anxiety is important. Providing emotional support and addressing concerns can help the patient manage anxiety associated with the diagnosis and impending surgery. This approach contributes to overall well-being and recovery.
Choice G reason:
Fluid volume management is vital in appendicitis care. Administering intravenous fluids, such as Ringer's lactate, maintains hydration, supports renal function, and prepares the patient for surgery. Proper fluid balance is essential for optimal physiological function.
Correct Answer is B
Explanation
Choice A reason: A cerebrovascular accident (CVA), commonly known as a stroke, occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. Although a severe headache might be a symptom of a stroke, it does not typically present with fever, nuchal rigidity, and a petechial rash, which are more indicative of an infection or inflammatory process.
Choice B reason: Meningococcal meningitis is a bacterial infection that causes inflammation of the membranes covering the brain and spinal cord. Symptoms often include a severe headache, fever, neck stiffness (nuchal rigidity), and a petechial rash, which is a distinguishing feature. This condition is a medical emergency and requires prompt antibiotic treatment to prevent serious complications or death.
Choice C reason: Intracerebral hemorrhage is bleeding within the brain tissue itself, which can be caused by various factors such as hypertension, aneurysms, or trauma. While it can cause a severe headache and neurological symptoms, it does not typically present with fever, nuchal rigidity, and a petechial rash, which suggest an infectious etiology rather than a hemorrhagic one.
Choice D reason: Rocky Mountain spotted fever is a tick-borne illness caused by the bacterium Rickettsia rickettsii. It can present with fever, headache, and a rash, but the rash is typically more generalized and not petechial. Additionally, the presence of nuchal rigidity and severe headache are more characteristic of meningitis rather than Rocky Mountain spotted fever.
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