A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia. The nurse would carefully monitor the client for which of the following manifestations?

Severe, throbbing headache

Hypotension

Fever

Cyanosis of the head and neck

Answer and Explanation

The Correct Answer is A

Choice A reason : A severe, throbbing headache is a common and significant manifestation of autonomic dysreflexia. This condition is a potentially life-threatening medical emergency that can occur in individuals with spinal cord injuries, typically above the T6 level. The headache results from a sudden and severe increase in blood pressure due to an exaggerated response of the autonomic nervous system to a stimulus below the level of the injury.

Choice B reason: Hypotension, or low blood pressure, is not a manifestation of autonomic dysreflexia. In fact, the condition is characterized by hypertension, or high blood pressure, which is a critical sign that requires immediate attention to prevent complications such as stroke or seizure.

Choice C reason: Fever is not a direct manifestation of autonomic dysreflexia. While a fever may indicate an infection or other systemic issue, autonomic dysreflexia itself is specifically associated with a rapid onset of high blood pressure and other autonomic disturbances.

Choice D reason: Cyanosis of the head and neck, which refers to a bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is not a typical manifestation of autonomic dysreflexia. The condition primarily causes hypertension and its associated symptoms, rather than issues with oxygenation.

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Correct Answer is B

Explanation

Choice A reason: Administering prescribed corticosteroids is not the appropriate action for dyspnea associated with fluid overload from IV infusion. Corticosteroids are typically used to manage inflammatory conditions and are not indicated for this scenario.

Choice B reason: Slowing the infusion rate is the correct action when signs of fluid overload are present, such as dyspnea and hypertension. This helps to prevent further fluid accumulation. Contacting the provider is essential for further evaluation and management, which may include adjusting the fluid regimen or prescribing diuretics to manage the fluid overload.

Choice C reason: Lowering the head of the bed to a semi-Fowler's position may provide temporary relief for dyspnea but does not address the underlying issue of fluid overload. It is a supportive measure but should be accompanied by other interventions to manage the client's condition.

Choice D reason: Changing the infusion to lactated Ringer's would not address the issue of fluid overload and could potentially exacerbate the situation if the rate is maintained. The type of IV fluid is less important than the volume and rate of administration in the case of fluid overload.

A. "I will increase the amount of fresh fruits and vegetables I consume." B. "I will be sure to wear gloves and wash my hands when I change my cat's litter box." C. "I will need to take my clothes to the dry cleaners to sterilize them." D. "I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash."

Correct Answer is B

Explanation

Choice A reason : While eating fresh fruits and vegetables is generally healthy, it does not specifically indicate an understanding of AIDS-related teaching. Some fruits and vegetables need to be carefully handled to avoid potential infections.

Choice B reason : Wearing gloves and washing hands after changing a cat's litter box is correct as it helps prevent the transmission of infections, such as toxoplasmosis, which can be particularly harmful to individuals with AIDS.

Choice C reason : Taking clothes to the dry cleaners for sterilization is unnecessary and does not reflect an understanding of AIDS-related precautions.

Choice D reason : Wiping up areas soiled with body fluids with alcohol and disposing of the trash is a good practice for infection control, but it is not as directly related to the client's understanding of AIDS-specific precautions as choice b.

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A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia. The nurse would carefully monitor the client for which of the following manifestations?

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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