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 C

Explanation

Choice A reason: Cheyne-Stokes respirations, characterized by a pattern of irregular breathing with periods of apnea, can be a sign of brain stem compression due to increased intracranial pressure. However, it is not typically the first sign of deteriorating neurological status.

Choice B reason: Pupillary dilation, especially if it is unilateral, can indicate pressure on the cranial nerves due to increased intracranial pressure. It is a concerning sign but may not be the first to appear as neurological function deteriorates.

Choice C reason: An altered level of consciousness is often the first sign of deteriorating neurological status in a patient with increased intracranial pressure. Changes in consciousness can range from slight disorientation or confusion to complete unresponsiveness.

Choice D reason: Decorticate posturing, which involves abnormal flexion of the arms with extension of the legs, indicates significant brain injury and is a later sign of increased intracranial pressure, not typically the first sign.

A. Respiratory rate of 24/min B. Adventitious breath sounds C. Weight loss of 1.8 kg (4 lb) in the past 24 hours D. Elevation in blood pressure

Correct Answer is C

Explanation

Choice A reason: A respiratory rate of 24/min is slightly higher than the normal range (12-20 breaths per minute) and does not necessarily indicate the effectiveness of furosemide in treating pulmonary edema.

Choice B reason: Adventitious breath sounds, such as crackles or wheezes, are often present in pulmonary edema and would not indicate that the furosemide is effective. The resolution of these sounds would be a better indicator of improvement.

Choice C reason: Weight loss of 1.8 kg (4 lb) in the past 24 hours likely indicates a reduction in fluid retention, which is a desired effect of furosemide in the treatment of pulmonary edema. This diuretic effect reduces the fluid overload, thereby improving the symptoms of pulmonary edema.

Choice D reason: An elevation in blood pressure is not an expected outcome of effective furosemide therapy for pulmonary edema. Furosemide is a diuretic and would more likely lead to a reduction in blood pressure due to fluid loss.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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