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.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Metabolic acidosis is characterized by a low pH and a low HCO3. However, George's HCO3 is within normal range, indicating that metabolic acidosis is not the primary issue.
Choice B reason: Partially compensated metabolic acidosis would present with a low pH and a low HCO3, along with a low PaCO2 as the body attempts to compensate. George's PaCO2 is elevated, which is not consistent with this condition.
Choice C reason: George's high PaCO2 and near normal HCO3 suggest that his primary issue is respiratory acidosis. The body has begun to compensate by retaining HCO3, making it partially compensated.
Choice D reason: Uncompensated respiratory acidosis would present with an elevated PaCO2 and a normal HCO3. Since George's HCO3 is elevated, it indicates partial compensation.
Correct Answer is D
Explanation
Choice A reason: Dependent rubor, a reddish coloration of the skin that occurs when the legs are in a dependent position, can be a sign of PAD, indicating poor arterial flow.
Choice B reason: Foot ulcers may occur in individuals with PAD due to poor blood circulation and the inability of sores or injuries to heal properly.
Choice C reason: Rest pain is a symptom of advanced PAD and occurs due to insufficient blood flow to the limbs even at rest, often worsening at night when the legs are elevated.
Choice D reason: Intermittent claudication, characterized by pain and cramping in the legs during exercise that disappears after rest, is a hallmark symptom of PAD and results from inadequate blood flow during increased activity.
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