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.

Answer and Explanation

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.

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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.

A. Auscultate lungs for unequal breath sounds. B. Continue to monitor the drainage system. C. Lift and clear drainage from the chest tube. D. Inspect the tube insertion site for leaking.

Correct Answer is B

Explanation

B. Tidaling is an expected finding in a functioning chest drainage system and indicates proper drainage of air or fluid from the pleural space. Continuously monitoring the drainage system allows the nurse to assess the volume, color, and consistency of drainage.
A. Rising water levels during inspiration and falling during expiration are indicative of proper chest tube function, therefore, auscultation for breath sounds may not provide additional relevant information related to the functioning of the chest tube.
C. Performing this action unnecessarily may disrupt the functioning of the drainage system and should only be done if specifically instructed by the healthcare provider.
D. While it is important to monitor for leaks, the observation of tidaling in the water-seal chamber does not necessarily indicate a leak at the insertion site.

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A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

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Correct Answer is A

Explanation

Correct Answer is B

Explanation

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