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 B
Explanation
B. Providing the client with a trapeze bar allows them to move and reposition in bed independently without compromising the traction on the affected leg.
A Checking pressure points every 2 hours is generally recommended for clients at risk of developing pressure ulcers, but it's not specific to skeletal traction care.
C. Removing the weights prematurely can lead to loss of traction and compromise the therapeutic benefit of the traction.
D. When a client has skeletal traction, they should avoid using the affected limb for any weight-bearing activities or for repositioning
Correct Answer is D
Explanation
D. The appropriate action would be to adjust the patient's position to restore the correct alignment and tension of the traction. This typically involves pulling the client up in bed to ensure that the weights hang freely and exert the necessary force for effective traction.
A It is not recommended to tie knots in the ropes as this action could disrupt the prescribed traction force and alignment.
B. It is helpful for other aspects of care but does not correct the traction issue caused by the weights resting on the floor.
C. This is not the correct action because it would decrease rather than increase the traction force, which is necessary for fracture alignment and healing.
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