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 B

Explanation

Choice A reason: This statement is incorrect. Synthetic casts typically dry much faster than plaster casts. Plaster casts can take 24 to 48 hours to fully harden, while synthetic casts made from materials like fiberglass or plastic can harden within a few hours.

Choice B reason: This is the correct statement. Synthetic casts are indeed lighter than plaster casts. They are made from materials like fiberglass, which is lighter than the traditional plaster of Paris used in plaster casts.

Choice C reason: This statement is incorrect. Plaster casts are generally heavier than synthetic casts. The weight of a cast can be an important consideration, especially for children or for those who may have difficulty managing a heavier cast.

Choice D reason: This statement is incorrect. Both plaster and synthetic casts require specialized equipment for application, but it is not specific to plaster casts. The application involves similar steps for both types, including the use of a stockinette, padding, and then the casting material itself.

A. Offer the client the bedpan every 2 hours. B. Cleanse the perineum from front to back. C. Encourage fluid intake at and between meals. D. Obtain a prescription for an indwelling urinary catheter.

Correct Answer is C

Explanation

Choice A reason: Offering the bedpan every 2 hours is not specifically related to preventing urinary tract infections (UTIs) and may not be necessary unless the client has other needs that require frequent toileting.

Choice B reason: Cleansing the perineum from front to back is a standard practice to prevent the spread of bacteria from the anal area to the urethra, which can reduce the risk of UTIs.

Choice C reason: Encouraging fluid intake is crucial for clients with a spinal cord injury because it helps to flush out the urinary tract, preventing the buildup of bacteria that can cause UTIs.

Choice D reason: An indwelling urinary catheter may be necessary for a client with a T4 spinal cord injury who cannot effectively empty the bladder, but it should be used with caution as it can also increase the risk of UTIs. The decision to use an indwelling catheter should be based on a thorough assessment and consideration of all other options.

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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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