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?
Place the client in a sitting position
Examine the client for areas of skin breakdown
Check the client's bladder for distention
Check the client for a fecal impaction
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 dysreflexia²³.
Choice B reason:While examining for skin breakdown is important, it is not the first action to take when autonomic dysreflexia is suspected.
Choice C reason:Checking the bladder for distention is a critical step, but it should be done after positioning the client to address immediate blood pressure concerns.
Choice D reason:Checking for fecal impaction is also important but follows the initial step of positioning the client to manage blood pressure.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Instructing the client to perform range-of-motion exercises to his lower extremities immediately after cardiac catheterization is not recommended. The client should maintain bed rest with the affected leg straight to prevent bleeding from the catheter insertion site.
Choice B reason: Ambulating the client 1 hour following the procedure is not advised. After femoral artery access, the client is typically required to remain on bed rest with the affected leg straight for several hours to ensure hemostasis and prevent bleeding².
Choice C reason: Restricting the client's fluid intake is not a standard post-procedure action. Adequate hydration is important after cardiac catheterization to help flush the contrast dye used during the procedure from the body, unless contraindicated.
Choice D reason: Assessing the color, temperature, and pulse in the affected extremity is crucial for detecting signs of bleeding, hematoma formation, or arterial occlusion. These assessments should be performed regularly as part of post-cardiac catheterization care².
Correct Answer is A
Explanation
Choice A reason: Disequilibrium syndrome is characterized by headache, nausea, and agitation, which can occur during or after hemodialysis, especially in the first few sessions as the body adjusts to the treatment².
Choice B reason: Septicemia would typically present with fever, chills, and hypotension, not specifically headache and agitation².
Choice C reason: Air embolism is a rare complication that would present with sudden respiratory distress, chest pain, and possibly hypotension, not just headache and agitation².
Choice D reason: Peritonitis is associated with abdominal pain and tenderness, fever, and possibly altered bowel movements, not the symptoms described².
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