A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?
An acutely distended bladder.
Profuse forehead diaphoresis.
Skeletal traction misalignment.
A severe pounding headache.
The Correct Answer is A
A. One of the most common triggers is a distended bladder. When the bladder becomes full, it sends signals to the spinal cord, but due to the injury, these signals are unable to pass beyond the level of injury. This results in uncontrolled sympathetic activation, leading to symptoms such as hypertension, sweating, and headache.
B. Forehead diaphoresis, or sweating, is a potential symptom of autonomic dysreflexia. However, it is more of a consequence rather than a precipitating factor. It occurs as a result of sympathetic nervous system activation in response to the triggering stimulus.
C. Skeletal traction misalignment is not a common precipitating factor for autonomic dysreflexia. Autonomic dysreflexia is typically triggered by stimuli related to visceral or autonomic reflexes, such as bladder distention or bowel impaction, rather than mechanical issues like traction misalignment.
D. A severe pounding headache can occur as a symptom of autonomic dysreflexia, but it is not the primary precipitating factor. The headache is a result of the sudden increase in blood pressure that occurs during autonomic dysreflexia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.6"]
Explanation
To determine how many milliliters (mL) of diazepam the nurse should administer to the client, first, we need to calculate the amount of medication needed for each dose.
The prescribed dose is 8 mg of diazepam.
Volume= Desired dose/available concentration per ml
Available concentration per ml= 10mg/2ml Available concentration per ml= 5mg/ml Volume= 8mg/5mg per ml
Volume= 1.6ml
So, the nurse should administer 1.6 mL of diazepam to the client.
Correct Answer is A
Explanation
Left ventricular dysfunction leads to inadequate stroke volume and cardiac output to the systemic circulation. This leads to fatigue and exertional dyspnea.
B. Lower extremity is a typical finding in right ventricular dysfunction. Inadequate pumping in the right ventricular leads to volume overload in the systemic circulation.
C. Hepatomegaly is a typical finding in right ventricular dysfunction
D. Jugular vein dysfunction is a typical finding in right ventricular dysfunction.
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