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.
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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Related Questions
Correct Answer is ["C","D","E"]
Explanation
Keeping a night light on in the client's room and bathroom can help reduce the risk of falls by improving visibility and orientation at night. Placing the bedside table within the client's reach can help reduce the risk of falls by making it easier for the client to access necessary items without having to get up and move around. Locking the wheels on beds and wheelchairs during transfers can help reduce the risk of falls by providing stability and preventing unwanted movement.
Keeping the bed at a comfortable working height is important for the nurse's comfort and safety while providing care, but it does not directly reduce the risk of falls for the client.
Administering a sedative at bedtime may help the client sleep, but it can also increase the risk of falls by causing drowsiness and disorientation.
Correct Answer is B
Explanation
The knee is a hinge type of joint. When describing range-of-motion exercises, the nurse should explain that the knee is a hinge joint. A hinge joint is a type of synovial joint that mainly allows for flexion and extension (and a small degree of medial and lateral rotation)¹. The knee joint is formed by articulations between the patella, femur, and tibia.
a. The knee is not a pivot joint.
c. The knee is not a ball and socket joint.
d. The knee is not a gliding joint.
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