A nurse is caring for a client who has a spinal cord injury.
For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.
Perform suctioning
Withhold pain medication for headache until other manifestations resolve.
Assess blood pressure every 15 min.
Administer nifedipine.
Assess for urinary retention.
Place client in supine position.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}
1. Perform suctioning
Contraindicated
Suctioning can be a stressor to the body, and in patients with autonomic dysreflexia, it could potentially exacerbate the condition and lead to further increases in blood pressure. In autonomic dysreflexia, managing the underlying trigger (such as a full bladder or bowel impaction) is key, not suctioning unless there is a specific need related to respiratory issues. This action could make the elevated blood pressure worse.
2. Withhold pain medication for headache until other manifestations resolve
Contraindicated
Pain management is critical in a patient with autonomic dysreflexia. The headache is a significant symptom of autonomic dysreflexia and needs to be addressed immediately, as pain is often the trigger. Withholding pain medication could worsen the client's symptoms and contribute to further complications. Proper management of pain should occur concurrently with interventions to address the elevated blood pressure.
3. Assess blood pressure every 15 minutes
Anticipated
Monitoring blood pressure is crucial in patients with autonomic dysreflexia to track changes and assess for improvement or worsening of hypertension. The nurse should frequently assess the client’s blood pressure to ensure it is returning to normal after appropriate interventions are initiated. Autonomic dysreflexia requires continuous monitoring of blood pressure to avoid complications such as stroke or cardiac events.
4. Administer nifedipine
Contraindicated
While nifedipine (a calcium channel blocker) is used to manage hypertension, it is not typically recommended as a first-line treatment for autonomic dysreflexia in spinal cord injury patients. Instead, interventions should focus on removing the triggering stimulus (e.g., bladder distension, constipation, or pressure ulcers). If blood pressure does not respond, other medications such as nitroglycerin or hydralazine may be used, but nifedipine is not the preferred option.
5. Assess for urinary retention
Anticipated
Urinary retention is a common trigger for autonomic dysreflexia in patients with spinal cord injuries, particularly those with injuries at or above T6. If the client is experiencing symptoms of autonomic dysreflexia, one of the first steps is to assess for urinary retention. If the bladder is full, catheterization may be required to relieve the pressure and help normalize the blood pressure. The nurse should assess the client’s urinary status promptly.
6. Place client in supine position
Contraindicated
In the case of autonomic dysreflexia, placing the client in a supine position could potentially worsen the elevated blood pressure by increasing venous return and making it harder for the body to normalize blood pressure. The client should be positioned sitting upright or at a 45-degree angle, which can help lower blood pressure by promoting venous pooling and reducing the effects of the autonomic dysreflexia response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This statement is appropriate because it respects the client’s autonomy and acknowledges that the client has the right to withdraw consent at any time.
B. Telling the client their doctor wouldn't have ordered the treatment unless it was necessary can be dismissive of the client’s concerns and feelings.
C. While it’s important to acknowledge that nervousness or anxiety is a normal response, this statement does not directly address the client’s concern about not proceeding with the treatment.
D. Telling the client that most people feel better after the procedure may sound dismissive of the
client’s hesitation and doesn’t address their concerns directly.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
The nurse should recognize that the client is experiencing preterm labor due toprevious preterm birth.
Rationale
Option 1: Preterm labor
The client’s symptoms are most consistent with preterm labor. Preterm labor is characterized by regular
uterine contractions before 37 weeks of gestation, cervical dilation and effacement, and sometimes vaginal discharge. In this case, the client has lower back pain, uterine contractions every 8 minutes, cervical dilation of 2 cm, and 50% effacement—all indicative of preterm labor.
Option 2: Previous Preterm Birth
The client's history of a preterm spontaneous vaginal birth at 30 weeks gestation increases the risk of preterm labor in the current pregnancy. The previous preterm birth is a known risk factor for future preterm labor.
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