A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreﬂexia. Which of the following interventions should the nurse take to prevent autonomic dysreﬂexia?

Monitor for elevated blood pressure.

Provide analgesia for headaches.

Prevent bladder distention.

Elevate the client's head.

Answer and Explanation

The Correct Answer is C

To prevent autonomic dysreﬂexia, the nurse should take the intervention of preventing bladder distention. Autonomic dysreﬂexia is a serious medical problem that can happen if a person has injured the spinal cord in their upper back¹. It makes their blood pressure dangerously high and can lead to a stroke, seizure, or cardiac arrest¹. One way to lower the chance of complications is to use the bathroom on a regular schedule and keep the bladder and bowels from becoming too full.

a. Monitoring for elevated blood pressure is important but not an intervention to prevent autonomic dysreﬂexia.
b. Providing analgesia for headaches is important but not an intervention to prevent autonomic dysreﬂexia.
d. Elevating the client's head is important but not an intervention to prevent autonomic dysreﬂexia.

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Correct Answer is B

Explanation

The nurse should identify that developing a respiratory infection can cause a myasthenic crisis in a client who has myasthenia gravis. A myasthenic crisis is a sudden worsening of myasthenia gravis symptoms, which can include difficulty breathing and swallowing. Respiratory infections can exacerbate these symptoms and trigger a myasthenic crisis.

Taking too much-prescribed medication, insufficient exercise, and insufficient sleep are not factors that can cause a myasthenic crisis. Taking too much-prescribed medication can cause side eﬀects but would not directly cause a myasthenic crisis. Insufficient exercise and insufficient sleep can worsen overall health but would not directly cause a myasthenic crisis.

A. Apply the elastic compression dressing tight enough so the toes and ankle become numb. B. Place moderate weight on the aﬀected leg when walking. C. Elevate the aﬀected ankle to the level of the heart. D. Apply heat during the first 24 hr.

Correct Answer is C

Explanation

The nurse should instruct the client to elevate the aﬀected ankle to the level of the heart. Elevation helps to reduce swelling and pain by promoting venous return and decreasing blood ﬂow to the injured area. This is an important part of the RICE (Rest, Ice, Compression, Elevation) method for treating sprains and strains.

a. The elastic compression dressing should not be applied so tight that it causes numbness in the toes and ankle.
b. The client should avoid placing weight on the aﬀected leg when walking until advised by a healthcare provider.
d. Heat should not be applied during the first 24 hours after a sprain as it can increase swelling and inﬂammation.

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A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreﬂexia. Which of the following interventions should the nurse take to prevent autonomic dysreﬂexia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is assisting with the care of a client who has myasthenia gravis and is in crisis. The nurse should identify that which of the following factors can cause a myasthenic crisis?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who has an ankle sprain. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?