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?

Choice A reason: Monitoring vital signs is crucial to assess the client's current condition and detect any further deterioration. Changes in vital signs can indicate the effectiveness of the treatment and whether additional interventions are needed. For instance, if the heart rate continues to rise or oxygen saturation drops further, it suggests that the client's condition is worsening and requires immediate attention. Keeping a close eye on the vital signs helps the healthcare team to make timely decisions and adjust the treatment plan as necessary.

Choice B reason: Administering additional nebulizer treatment is necessary because the client is still experiencing shortness of breath and bilateral wheezes even after the initial medication. Nebulizer treatments, such as those containing albuterol and ipratropium, help to relax and open the airways, making breathing easier. Given the client's severe asthma symptoms and the fact that the previous doses were not completely effective, additional treatment can provide the needed relief and prevent further respiratory distress.

Choice C reason: Increasing the oxygen flow rate is essential to improve the client's oxygen saturation levels. The current oxygen saturation of 91% indicates hypoxemia, which can lead to severe complications if not addressed promptly. By increasing the flow rate, the client can receive a higher concentration of oxygen, helping to maintain adequate oxygenation of tissues and organs. Continuous monitoring of oxygen saturation is also important to ensure that the increased flow rate is effective and to make further adjustments if needed.

Choice D reason: Raising the head of the bed helps to facilitate easier breathing for the client. This position allows gravity to assist in the expansion of the lungs and reduces the pressure on the diaphragm, making it easier for the client to take deeper breaths. It also helps to reduce the work of breathing and can be particularly beneficial for clients experiencing respiratory distress. Ensuring that the client is in a comfortable and optimal position for breathing is an important aspect of asthma management.

Choice E reason: While providing a spirometer can be useful for lung function exercises, it is not the immediate priority in this acute situation. The client's primary concern is to stabilize their breathing and ensure adequate oxygenation. Once the client is stable, a spirometer can be introduced as part of long-term management and rehabilitation to improve lung function and monitor progress.

Choice A reason: Overall fluid intake should not be limited. In fact, increasing fluid intake is generally recommended to help flush out the urinary system and prevent the formation of new stones. Adequate hydration is key to preventing urinary tract calculi.

Choice B reason: Citrus fruit juices, such as orange juice and grapefruit juice, should be limited because they can increase the acidity of the urine. High acidity can contribute to the formation of certain types of kidney stones, particularly uric acid stones. Limiting citrus fruit juices can help reduce the risk of stone recurrence.

Choice C reason: Low-sodium sodas are generally better than regular sodas, but it is important to note that many sodas, even low-sodium ones, contain high levels of phosphates and other substances that can contribute to kidney stone formation. While low-sodium sodas are a better option, the primary focus should be on overall healthy fluid choices.

Choice D reason: Tea and hot chocolate should be limited due to their oxalate content. Oxalates can bind with calcium in the urine to form calcium oxalate stones, which are the most common type of kidney stones. Limiting the intake of tea and hot chocolate can help reduce the risk of stone formation.