A nurse is caring for a client who has a spinal cord injury and is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

Place the client in a sitting position

Check the client for a fecal impaction

Examine the client for areas of skin breakdown

Check the blood pressure for discrepancies

Answer and Explanation

The Correct Answer is A

Choice A reason: Placing the client in a sitting position helps to lower blood pressure by promoting venous return and is the first action to take in cases of autonomic dysreflexia.

Choice B reason: Checking for a fecal impaction is important as it can be a trigger for autonomic dysreflexia, but it is not the first action to take.

Choice C reason: Examining for areas of skin breakdown is part of ongoing care for clients with spinal cord injuries but is not the immediate priority in autonomic dysreflexia.

Choice D reason: Checking blood pressure is important for monitoring the severity of autonomic dysreflexia, but the first action is to address the positioning of the client to manage the hypertensive crisis.

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Correct Answer is C

Explanation

Choice A reason: Fatigue is a common symptom of ITP but is not the primary concern for monitoring, as it does not directly indicate the severity of the condition.

Choice B reason: While monitoring for side effects of immunosuppressants is important, it is not the priority concern. The primary issue in ITP is the low platelet count, which poses a risk of bleeding.

Choice C reason: Thrombocytopenia, or low platelet count, is the hallmark of ITP and the main concern for monitoring, as it increases the risk of bleeding and bruising.

Choice D reason: Infection is a risk due to the potential use of immunosuppressants in treatment; however, the immediate concern in ITP management is the platelet count and associated bleeding risk.

A. Pain at rest B. Thin, brittle toenails C. Hanging legs D. Cool extremities

Correct Answer is A

Explanation

Choice A reason: Pain at rest is a common symptom of advanced PAD, indicating that blood flow is so reduced that the muscles are not receiving enough oxygen even when not active.

Choice B reason: Thin, brittle toenails can be a sign of PAD due to poor blood flow affecting the growth and health of the nails.

Choice C reason: Hanging legs, or dependent positioning, may temporarily relieve pain for PAD patients due to gravity assisted blood flow; however, it is not a finding but rather a coping mechanism.

Choice D reason: Cool extremities are expected in PAD because reduced blood flow decreases the warmth supplied to the tissues.

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A nurse is caring for a client who has a spinal cord injury and is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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