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 Sputum cultures for AFB are used to detect the presence of Mycobacterium tuberculosis, the bacteria causing TB. A negative result means that the sputum samples tested do not contain viable TB bacteria that can be transmitted to others. It indicates that the client's TB treatment has been effective in reducing the bacterial load to non-infectious levels.
B. The Quantiferon-TB Gold test is a blood test used to detect TB infection based on the immune response to TB antigens. A positive result indicates TB infection but does not differentiate between latent TB infection (not infectious) and active TB disease (potentially infectious).
C. The Mantoux tuberculin skin test (TST) is another test used to detect TB infection based on a delayed- type hypersensitivity reaction to TB antigens. An induration of less than 1 mm is considered negative and suggests that the client does not have a significant immune response to TB antigens, which could mean they are not infected with TB or the infection is not significant. This finding does not provide information on the client's infectiousness.
D. This indicates improvement in the client's symptoms, as coughing up blood-tinged sputum (hemoptysis) is a common symptom of active pulmonary TB. While improvement in symptoms is an important aspect of TB treatment, it does not directly indicate whether the client is no longer infectious. Infectiousness is primarily determined by microbiological tests such as sputum cultures for AFB.
Correct Answer is C
Explanation
C. Lowering the bed height reduces the risk of injury in case the client falls out of bed. It also facilitates easier transfers for clients with mobility issues.
A Individuals with dementia may experience disorientation and confusion, especially in unfamiliar or dark environments. Turning off all lights can increase the risk of falls and accidents.
B. Clients with dementia may have difficulty recognizing the need to toilet or may forget where the bathroom is located. They may also have urinary or fecal incontinence. Scheduled toileting helps prevent accidents and promotes continence.
D. Sedatives or hypnotic medications can increase confusion, risk of falls, and adverse effects in older adults with dementia. They are generally not recommended as first-line treatment for sleep disturbances in dementia.
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