A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

Title: Choice A reason: Liver enzymes Liver enzymes are proteins that speed up chemical reactions in your body. They include alanine transaminase (ALT), aspartate transaminase (AST), and alkaline phosphatase (ALP). High levels of liver enzymes in the blood can indicate liver disease. However, rheumatic endocarditis is a heart condition, not a liver condition. Therefore, while liver enzymes are important for diagnosing liver conditions, they would not assist in confirming a diagnosis of rheumatic endocarditis.

Title: Choice B reason: Serum albumin Serum albumin is a type of protein that your liver and kidneys produce to help your body maintain fluid balance and function. Low or high albumin levels can indicate liver disease, kidney disease, or nutritional deficiency. However, rheumatic endocarditis is a heart condition, not a liver or kidney condition. Therefore, while serum albumin is important for diagnosing liver and kidney conditions, it would not assist in confirming a diagnosis of rheumatic endocarditis.

Title: Choice C reason: Throat culture A throat culture is a lab test used to find and identify germs in the back of your mouth that are making you sick. It can diagnose infections like strep throat, gonorrhea, thrush, diphtheria, and pertussis. Rheumatic endocarditis is often caused by a streptococcal infection, which can be identified through a throat culture. Therefore, a throat culture would assist in confirming a diagnosis of rheumatic endocarditis.

Title: Choice D reason: Arterial blood gases An arterial blood gas (ABG) test measures the levels of oxygen and carbon dioxide in your blood as well as the pH balance in your blood. It helps diagnose and monitor conditions that affect your respiratory, circulatory, and metabolic systems. However, rheumatic endocarditis is a heart condition that is often caused by a bacterial infection. Therefore, while an ABG test is important for diagnosing conditions that affect your respiratory, circulatory, and metabolic systems, it would not assist in confirming a diagnosis of rheumatic endocarditis.

Choice A reason: Anorexia, or loss of appetite, is not typically a direct manifestation of left-sided heart failure. While it can be associated with many medical conditions and may occur in the context of heart failure due to overall decreased well-being, it is not a specific indicator of left-sided heart failure.

Choice B reason: Weight gain can be associated with heart failure, but it is more commonly a sign of right-sided heart failure, where fluid accumulates in the body tissues, causing swelling and weight increase. In left-sided heart failure, weight gain is not as prominent because the primary issue is the backup of blood into the lungs, not fluid retention in the tissues.

Choice C reason: A distended abdomen can occur in heart failure due to fluid accumulation; however, it is more characteristic of right-sided heart failure, where the failure of the right ventricle leads to systemic congestion, including the abdominal area. In left-sided heart failure, the primary effect is on the lungs, not the abdomen.

Choice D reason: Dyspnea, or difficulty breathing, is a hallmark symptom of left-sided heart failure. It occurs due to the backup of blood in the pulmonary circulation, which leads to pulmonary congestion and reduced oxygen exchange. Patients may experience shortness of breath, especially during exertion or when lying flat (orthopnea), and may wake up at night with shortness of breath (paroxysmal nocturnal dyspnea).

Left-sided heart failure, often caused by conditions like valvular heart disease, leads to a decrease in the heart’s ability to pump blood effectively. This results in a buildup of pressure in the lungs, manifesting as dyspnea, which is an important symptom for nurses and other healthcare providers to recognize and manage promptly.