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

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A reason:Atrial fibrillation is not typically treated with defibrillation; it is usually managed with medication or other forms of rhythm control.

Choice B reason:Supraventricular tachycardia does not usually require defibrillation; it may be treated with vagal maneuvers or medication.

Choice C reason:Asystole, or the absence of a heartbeat, is not treated with defibrillation as there is no electrical activity to reset.

Choice D reason:Ventricular fibrillation is a life-threatening heart rhythm that requires immediate defibrillation to restore a normal heart rhythm.

A. Heart murmur B. Dependent edema C. Chest pain D. Crackles in the lungs

Correct Answer is B

Explanation

Choice A reason: A heart murmur is not a common finding in right-sided heart failure unless there is an associated valvular heart disease.

Choice B reason: Dependent edema is a classic sign of right-sided heart failure due to the accumulation of fluid in the tissues, particularly in the lower extremities.

Choice C reason: Chest pain is more commonly associated with left-sided heart failure or other cardiac conditions such as angina.

Choice D reason: Crackles in the lungs are typically found in left-sided heart failure due to pulmonary congestion, not right-sided heart failure.

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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?

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Naxlex Comprehensive Predictor Exams

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