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 D
Explanation
Choice A reason: Infusing packed RBCs over 1 hour is typically too rapid for most patients and can increase the risk of adverse reactions, especially in those with cardiovascular compromise.
Choice B reason: A 2hour infusion may be appropriate in certain emergency situations where rapid correction of anemia is required, but it is not the standard practice for routine transfusions.
Choice C reason: A 3hour infusion is less commonly used and does not provide any specific advantage over the standard 4hour infusion time.
Choice D reason: The standard practice is to complete the transfusion of packed RBCs within 4 hours. This duration minimizes the risk of bacterial growth and transfusion reactions, as recommended by the American Society of Hematology and other clinical guidelines.
Correct Answer is C
Explanation
Choice A reason: Dehydration is a concern with fever, but it is not a direct complication of hypothermia blanket therapy. It is important to ensure adequate hydration, but the primary concern with hypothermia therapy is not dehydration.
Choice B reason: Burns could occur if the hypothermia blanket malfunctions or is used improperly. However, modern devices have safety features to prevent burns, making this a less likely complication.
Choice C reason: Shivering is a natural response to cooling and can occur as the body attempts to generate heat in response to the lowered temperature from the hypothermia blanket. It can be counterproductive to the therapy and may need to be controlled with medications.
Choice D reason: Seizures are not a typical complication of hypothermia blanket therapy. While meningitis can cause seizures due to inflammation of the brain, the hypothermia blanket itself does not induce seizures.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.