A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Choice A reason: A distended bladder is a common cause of autonomic dysreflexia. It can trigger an exaggerated response from the autonomic nervous system, leading to a rapid increase in blood pressure. This is because the full bladder sends signals to the spinal cord, which then attempts to send signals to the brain. However, due to the injury, these signals cannot pass through, resulting in a reflex that increases blood pressure.

Choice B reason: While a severe headache is a symptom of autonomic dysreflexia, it is not a cause. The headache results from the body's response to a triggering stimulus, such as a distended bladder, which leads to the high blood pressure characteristic of autonomic dysreflexia.

Choice C reason: Nasal congestion is not typically a cause of autonomic dysreflexia. The condition is usually triggered by a noxious stimulus below the level of the spinal cord injury, such as a full bladder or bowel, skin irritation, or other types of physical discomfort.

Choice D reason: Elevated blood pressure is a symptom, not a cause, of autonomic dysreflexia. The condition itself causes a sudden spike in blood pressure due to an uncontrolled reflex sympathetic discharge in response to a triggering stimulus below the level of the injury.

Choice A reason: A fractured femur, while a serious injury, does not inherently contraindicate the use of lipid emulsions. These patients may require additional nutrition if they are unable to eat adequately by mouth, and lipid emulsions can be part of their parenteral nutrition regimen if needed.

Choice B reason: Severe anorexia nervosa is a condition that can lead to malnutrition and may necessitate the use of parenteral nutrition, including lipid emulsions, to provide essential nutrients. However, care must be taken to avoid refeeding syndrome, a potentially fatal condition that can occur when malnourished patients begin to refeed too quickly.

Choice C reason: Gastrointestinal obstruction is a condition that could be exacerbated by the administration of lipid emulsions. In cases of obstruction, enteral or parenteral nutrition may need to be carefully managed or avoided until the obstruction is resolved to prevent further complications. While lipid emulsions are a valuable component of parenteral nutrition, their use must be carefully considered in the context of the patient’s overall clinical condition. In the case of gastrointestinal obstruction, the nurse would be most concerned about the prescription of a lipid emulsion due to the potential for exacerbating the obstruction and complicating the patient’s condition.

Choice D reason: Chronic diarrhea and vomiting can lead to dehydration and electrolyte imbalances, but they do not directly contraindicate the use of lipid emulsions. However, the underlying cause of these symptoms should be addressed, and fluid and electrolyte balance should be carefully monitored.