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 D
Explanation
A. Fibromyalgia is not a contraindication for combination oral contraceptives.
B. Fibrocystic breast disease is not a contraindication, though it may require monitoring.
C. Renal calculi are not a contraindication for oral contraceptive use.
D. Hypertension is a contraindication because it increases the risk of cardiovascular complications when using combination oral contraceptives.
Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B,C"},"E":{"answers":"A"}}
Explanation
Hypercapnia (elevated PaCO2)
Malignant hyperthermia: Yes. Malignant hyperthermia (MH) is a life-threatening condition triggered by certain anesthetic agents, and it leads to hypermetabolism, muscle rigidity, and hypercapnia (elevated carbon dioxide levels.
Latex allergy: No. Hypercapnia is not associated with latex allergy.
Hypovolemic shock: Yes. In hypovolemic shock, hypercapnia can occur as a compensatory response due to tissue hypoxia and poor perfusion. However, it is less directly characteristic of hypovolemic shock than of malignant hyperthermia.
2. Wheezes
Malignant hyperthermia: No. Wheezing is not a typical feature of malignant hyperthermia. Instead, it is primarily characterized by muscle rigidity, hypercapnia, and tachycardia.
Latex allergy: Yes. A latex allergy can cause respiratory symptoms, including wheezing, shortness of breath, or bronchospasm. This can occur when an allergic reaction triggers an asthma-like response in the airways.
Hypovolemic shock: No. Wheezing is not characteristic of hypovolemic shock. Hypovolemic shock primarily involves signs of decreased blood volume and perfusion, such as tachycardia, hypotension, and altered mental status.
3. Urticaria (hives)
Malignant hyperthermia: No. Urticaria is not a feature of malignant hyperthermia. MH is characterized by hyperthermia, muscle rigidity, and tachycardia, not an allergic skin reaction.
Latex allergy: Yes. Urticaria (hives) is a common sign of a latex allergy. An allergic reaction to latex can lead to skin reactions, including hives, itching, or rash.
Hypovolemic shock: No. Urticaria is not a typical finding in hypovolemic shock. In hypovolemic shock, the primary concern is hypotension, tachycardia, cool, clammy skin, and poor perfusion, not skin reactions like hives.
4. Tachycardia
Malignant hyperthermia: Yes. Tachycardia is a prominent feature of malignant hyperthermia, often occurring alongside hyperthermia (high body temperature) and muscle rigidity. The elevated heart rate is a response to the increased metabolic demand and stress during MH.
Latex allergy: Yes. Tachycardia can be a response to an allergic reaction such as latex allergy. In more severe cases, anaphylaxis due to latex exposure can cause a rapid heart rate as part of the body's response to the allergic reaction.
Hypovolemic shock: Yes. Tachycardia is a compensatory mechanism in hypovolemic shock. As the body tries to compensate for fluid loss or reduced blood volume, the heart rate increases to maintain perfusion.
5. Muscle rigidity
Malignant hyperthermia: Yes. Muscle rigidity is a classic sign of malignant hyperthermia. It occurs as a result of abnormal muscle contraction, leading to increased metabolic activity, hyperthermia, and hypercapnia.
Latex allergy: No. Muscle rigidity is not a typical feature of latex allergy.
Hypovolemic shock: No. Muscle rigidity is not characteristic of hypovolemic shock, which is primarily marked by reduced blood volume, hypotension, and poor perfusion.
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