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: Eating foods at room temperature can help reduce nausea because strong odors from hot foods can increase the feeling of nausea.
Choice B reason: Increasing unsaturated fats is not specifically related to managing nausea and may not be beneficial in this context.
Choice C reason: Drinking more liquids with meals can sometimes increase nausea; it's often recommended to drink fluids between meals instead.
Choice D reason: Eating smaller meals can help manage nausea because large meals can overwhelm the digestive system when it's sensitive due to treatment.
Correct Answer is C
Explanation
Choice A reason: Weighing the client daily is important for monitoring fluid balance but is not the most immediate action to prevent an Addisonian crisis.
Choice B reason: Restricting fluid intake is not appropriate for a client at risk for Addisonian crisis, as they may require increased fluids to prevent dehydration.
Choice C reason: This is the correct action. Clients with Addison's disease require corticosteroids to replace the hormones that their adrenal glands are not producing.
Choice D reason: Providing a low carbohydrate diet is not relevant to the prevention of an Addisonian crisis.
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