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 Pertussis is highly contagious and spread through respiratory droplets. Wearing a surgical mask when providing care to the client helps prevent the spread of the bacteria to others in the healthcare setting. This is a standard precaution to minimize transmission of respiratory infections.
B. A Mantoux test, or tuberculin skin test, is used to detect tuberculosis (TB) infection, not pertussis. It is not relevant to the diagnosis or management of pertussis. The focus should be on clinical assessment and appropriate treatment for pertussis.
C Pertussis does not typically require isolation in a negative pressure airflow room. Standard precautions, including wearing a surgical mask, are generally sufficient to prevent transmission. Negative pressure rooms are typically reserved for airborne infections like tuberculosis or measles.
D. Pertussis is caused by a bacterial infection (Bordetella pertussis), not a virus. Antiviral therapy is not effective against bacterial infections such as pertussis. Family members and close contacts of the client should receive prophylactic antibiotics to prevent spread of the infection, not antiviral therapy.
Correct Answer is C
Explanation
B. This statement indicates understanding of preventive measures to reduce the risk of transmitting genital herpes to sexual partners. Using condoms, including natural skin (non-latex) condoms, can help reduce the risk of transmission.
A Antiviral medications for genital herpes are typically prescribed to manage outbreaks and reduce symptoms, but the duration can vary depending on the severity of symptoms and recurrence.
b. People with genital herpes should use latex or polyurethane condoms during sexual intercourse, as these are effective at reducing the risk of transmitting the virus. Natural skin condoms (e.g., lambskin condoms) do not provide an effective barrier against the herpes virus because they have tiny pores that can allow the virus to pass through, potentially leading to transmission.
C. These typically heal within 2-4 weeks. While some might take longer, 6 weeks provides a reasonable timeframe for most cases.
D. Antibiotic ointments are not effective against viruses such as herpes simplex virus (HSV). Treatment for genital herpes typically involves antiviral medications
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