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 C

Explanation

The nurse should anticipate that the provider will initially prescribe acetaminophen to the client who has a new diagnosis of osteoarthritis. Acetaminophen (Tylenol, others) has been shown to help some people with osteoarthritis who have mild to moderate pain². It is often used as a first-line treatment for osteoarthritis pain.

a. Hyaluronic acid is not typically the first medication prescribed for osteoarthritis.
b. Ibuprofen may be prescribed for osteoarthritis but is not typically the first medication prescribed.
d. Celecoxib may be prescribed for osteoarthritis but is not typically the first medication prescribed.

A. Edematous bruise on forehead B. Client disoriented to place C. Heart rate 110/min and regular D. Small drops of clear ﬂuid in left ear

Correct Answer is D

Explanation

The nurse should immediately report small drops of clear ﬂuid in the left ear to the charge nurse. This finding could indicate a cerebrospinal ﬂuid (CSF) leak, which can occur as a result of a head injury. A CSF leak can be a serious medical condition that requires immediate attention.

An edematous bruise on the forehead, client disorientation to place, and a heart rate of 110/min and regular are also important findings that the nurse should report to the charge nurse. However, these findings are not as urgent as the presence of small drops of clear ﬂuid in the left ear.

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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?

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Correct Answer is D

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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?

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