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 A

Explanation

Choice A reason:Using a microwave to warm the solution is not recommended as it can lead to uneven heating and potentially damage the solution or harm the patient.

Choice B reason: The statement about the catheter becoming infected despite sterile precautions is accurate and reflects an understanding of the risks associated with peritoneal dialysis.

Choice C reason:Expecting the volume of the output solution to be greater than the input solution is incorrect; typically, the volumes should be equal to ensure proper fluid removal.

Choice D reason: The fluid from the abdomen being clear or slightly yellow is a normal finding and does not indicate a need for further teaching.

A. Aspiration B. Gastroesophageal reflux disease C. Peptic ulcer disease D. Dumping syndrome

Correct Answer is A

Explanation

Aspiration is a common complication in patients with dysphagia post-stroke due to impaired swallowing reflexes, leading to food or liquid entering the lungs.

Choice B reason: Gastroesophageal reflux disease could be a concern but is not directly related to dysphagia post-stroke.

Choice C reason: Peptic ulcer disease is not typically a complication of dysphagia post-stroke.

Choice D reason: Dumping syndrome is related to rapid gastric emptying post-meal, not dysphagia post-stroke.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about self-administering peritoneal dialysis. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who had a stroke and has dysphagia. For which of the following complications should the nurse monitor the client?

Correct Answer is A

Explanation

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