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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Applying antibiotic ointment to the lesions is not recommended for the treatment of genital herpes, which is caused by a virus, not bacteria. Antiviral medications are the appropriate treatment for managing herpes outbreaks.
Choice B reason: Natural skin condoms are not effective in preventing the transmission of genital herpes because the virus can pass through the natural membrane. The use of latex or polyurethane condoms is recommended as they are more effective in reducing the risk of transmission.
Choice C reason: Expecting lesions to resolve in 6 weeks may not be accurate as the duration of a herpes outbreak can vary. Most herpes lesions tend to resolve within 2 to 4 weeks. However, the virus remains in the body and can cause recurrent outbreaks.
Choice D reason: The duration of medication for genital herpes depends on whether the treatment is for an initial outbreak, chronic suppression, or episodic therapy. For an initial outbreak, antiviral medication is typically taken for 7 to 10 days. For chronic suppression, medication might be taken daily for an extended period to prevent or reduce the frequency of outbreaks.
Correct Answer is B
Explanation
Choice A reason: Droplet precautions are used for diseases that are transmitted through large respiratory droplets produced by coughing, sneezing, or talking. AIDS, caused by the Human Immunodeficiency Virus (HIV), is not transmitted through respiratory droplets, so droplet precautions are not necessary for a client with AIDS.
Choice B reason: Standard precautions are the primary strategy for the prevention of infection transmission and apply to all patients receiving care in hospitals, regardless of their diagnosis or presumed infection status. These precautions include hand hygiene, the use of personal protective equipment (PPE) like gloves and gowns, and safe injection practices. Since HIV/AIDS can be transmitted through blood and certain body fluids, standard precautions are essential when caring for clients with AIDS.
Choice C reason: Airborne precautions are used for diseases that are transmitted by small droplet nuclei that remain suspended in the air and can be widely dispersed by air currents within a room or over a long distance. HIV/AIDS is not transmitted through the airborne route, so airborne precautions are not indicated for clients with AIDS.
Choice D reason: Contact precautions are used for infections that are spread by direct contact with the patient or indirect contact with surfaces or patient care items. While HIV can be present in body fluids, it is not easily transmitted through casual contact. Therefore, contact precautions are not specifically required for clients with AIDS unless they have other conditions that warrant such precautions.
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