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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Correct Answer is ["167"]
Explanation
- Step 1: Identify the client's weight in pounds. The client weighs 245 lbs.
- Step 2: Convert the client's weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, 245 lbs = 245 ÷ 2.2 kg. Calculating the division gives us approximately 111.36 kg.
- Step 3: Identify the prescribed dose in mg/kg. The client is scheduled to receive 1.5 mg/kg of enoxaparin.
- Step 4: Calculate the total dose in mg. We can do this by multiplying the client's weight in kg by the prescribed dose in mg/kg:
- Total dose = 1.5 mg/kg × 111.36 kg.
- Calculating the multiplication gives us approximately 167.04 mg.
- Step 5: Round the total dose to the nearest whole number. Rounding 167.04 gives us 167.
administer 167 mg of enoxaparin per dose.
Correct Answer is B
Explanation
Choice A reason:Placing a cool cloth on the forehead may provide comfort but does not address intracranial pressure, which could be causing the headache[^10^].
Choice B reason:Elevating the head of the bed 30 degrees helps to decrease intracranial pressure and can alleviate headache symptoms associated with a closed head injury[^10^].
Choice C reason:Administering morphine for pain relief should be done with caution, as it can depress respiration and mask changes in the level of consciousness, which are important indicators of neurological status[^10^].
Choice D reason:A lumbar puncture is contraindicated in the presence of increased intracranial pressure due to the risk of brain herniation[^10^].
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