A nurse is caring for a client who has a spinal cord injury and has developed autonomic dysreflexia. Identify the sequence of steps the nurse should take.
(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Administer an antihypertensive medication intravenously.
Confirm that the client's bladder is empty.
Indicate the risk for autonomic dysreflexia in the client's medical record.
Place the client in an upright sitting position.
The Correct Answer is D,B,A,C
Step D (Place the client in an upright sitting position): Elevating the client's head and upper body to an upright position helps to reduce blood pressure by promoting venous pooling in the lower extremities.
Step B (Confirm that the client's bladder is empty): Autonomic dysreflexia is often triggered by bladder distention or urinary retention. By confirming and addressing urinary issues promptly, the nurse can remove the triggering stimulus.
Step A (Administer an antihypertensive medication intravenously): In severe cases where blood pressure remains dangerously high despite other interventions, such as positioning and addressing bladder issues, antihypertensive medications may be necessary to lower blood pressure quickly and prevent complications.
Step C (Indicate the risk for autonomic dysreflexia in the client's medical record): Documentation of the occurrence of autonomic dysreflexia, its triggers, and interventions used is essential for continuity of care. It informs other healthcare providers about the client's condition and helps in implementing preventive strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A Canola oil is a healthier choice compared to saturated fats like butter or coconut oil because it is lower in saturated fat and high in unsaturated fats (monounsaturated and polyunsaturated fats). Using canola oil can help lower LDL (bad) cholesterol levels and reduce the risk of heart disease.
B. Canned vegetables often contain added sodium as a preservative, which can contribute to hypertension (high blood pressure), a risk factor for cardiovascular disease. Therefore, increasing intake
of canned vegetables is not recommended for someone with cardiovascular disease unless they are choosing low-sodium or no-added-salt varieties.
C. Limiting portions of meat helps reduce intake of saturated fats, which can raise LDL cholesterol levels and increase the risk of heart disease. A portion size of 8 ounces is appropriate as part of a heart-healthy diet that emphasizes lean proteins and plant-based sources of protein.
D. Whole milk is higher in saturated fat compared to low-fat or skim milk. Consuming saturated fats increases LDL cholesterol levels, which can contribute to cardiovascular disease. Therefore, drinking whole milk is not recommended for someone with cardiovascular disease who should focus on reducing saturated fat intake.
Correct Answer is C
Explanation
C. Restlessness and agitation can be early signs of increased ICP. They result from the brain's attempt to compensate for the increasing pressure. Restlessness may indicate discomfort or confusion caused by cerebral edema or pressure on brain structures.
A Projectile vomiting can occur with increased ICP due to stimulation of the vomiting center in the brainstem as a response to pressure on the brain. It is a symptom that may indicate a more advanced increase in ICP rather than an early manifestation.
B. Papilledema refers to swelling of the optic disc due to increased intracranial pressure transmitting through the optic nerve sheath. It is typically a late manifestation of increased ICP rather than an early one. It requires time for pressure to build up and affect the optic nerve.
D. Decorticate posturing is a type of abnormal posture that can occur with severe brain injury or increased ICP. It involves flexion of the arms, wrists, and fingers with adduction of the upper extremities and extension of the lower extremities. This is typically a later sign of increased ICP
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