A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreﬂexia. Which of the following actions should the nurse take first?

Raise the head of the bed.

Check the client for a fecal impaction.

Check the client's bladder for distention.

Ensure the room temperature is warm.

Answer and Explanation

The Correct Answer is A

If a nurse is caring for a client who has a spinal cord injury and suspects that the client has autonomic dysreﬂexia, the first action the nurse should take is to raise the head of the bed. This can help to lower the client's blood pressure and reduce the risk of complications such as stroke.

b. Checking the client for a fecal impaction is an important step in identifying and treating the underlying cause of autonomic dysreﬂexia, but it is not the first action the nurse should take.
c. Checking the client's bladder for distention is an important step in identifying and treating the underlying cause of autonomic dysreﬂexia, but it is not the first action the nurse should take.
d. Ensuring that the room temperature is warm is not a priority intervention for a client who has autonomic dysreﬂexia.

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Correct Answer is A

Explanation

a.A GCS score of 8 indicates severe impairment, suggesting the client may be in a state where they cannot perform basic self-care activities and thus require total nursing care.

b.A GCS score of 8 indicates severe impairment but not necessarily a deep coma. Scores below 8 suggest a comatose state, but deep coma is more likely to be indicated by a score of 3-4.

c.A GCS score of 8 is not consistent with a client who is alert and oriented. This score indicates significant neurological impairment.

d.A GCS score of 8 does not indicate stable neurological status. It suggests severe impairment and potentially unstable or deteriorating neurological condition.

A. Perform passive range of motion on each extremity. B. Record the client's intake and output. C. Suction saliva from the client's mouth. D. Monitor the client's electrolyte levels.

Correct Answer is C

Explanation

The highest priority nursing intervention for a client who is unconscious following a stroke is to suction saliva from the client's mouth. This can help prevent aspiration and maintain a patent airway, which is essential for the client's survival.

Performing passive range of motion on each extremity, recording the client's intake and output, and monitoring the client's electrolyte levels are also important nursing interventions for this client. However, these interventions are not as high of a priority as maintaining a patent airway.

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A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreﬂexia. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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