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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Right lower quadrant.
McBurney's point is located in the right lower quadrant of the abdomen, which is one-third of the distance from the anterior superior iliac spine to the umbilicus. This is the area where tenderness is most likely to be maximal in cases of acute appendicitis.
Choice B reason: Left lower quadrant
The left lower quadrant is not typically associated with appendicitis pain, as the appendix is located in the right lower quadrant of the abdomen.
Choice C reason: Right upper quadrant
The right upper quadrant is generally associated with other conditions such as gallbladder issues, not appendicitis.
Choice D reason: The left upper quadrant
The left upper quadrant is also not associated with appendicitis pain, as it is on the opposite side of the typical location of the appendix.
Correct Answer is B
Explanation
Choice A reason: Applying a tourniquet just below the elbow is not recommended as the first line of action for a deep laceration unless there is life-threatening hemorrhaging that cannot be controlled by direct pressure. Tourniquets are used as a last resort because they can cause tissue damage.
Choice B reason: Elevating the limb and applying ice can help reduce bleeding and swelling. Elevation uses gravity to help reduce blood flow to the injury, and the cold from the ice constricts blood vessels, further helping to control bleeding and reduce swelling.
Choice C reason: Cleaning the wound is important, but it should not be the first action taken. The initial focus should be on stopping the bleeding. Once bleeding is controlled, the wound can be cleaned to prevent infection.
Choice D reason: Applying pressure directly to the wound with a clean cloth or bandage is the first step in controlling bleeding. However, the question specifies applying pressure above the wound, which would not be effective in controlling bleeding from the wound itself.
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