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.
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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Related Questions
Correct Answer is C
Explanation
The priority intervention for the nurse to implement for a newly-admitted client who has acute osteomyelitis is antibiotic therapy. Osteomyelitis is an inflammatory condition of bone secondary to an infectious process¹. Antibiotics are the primary treatment option and should be tailored based on culture results and individual patient factors.
a. Optimal nutrition and hydration is important but not the priority intervention.
b. Surgical debridement of necrotic tissue may be necessary but is not the priority intervention.
d. Antipyretic therapy may be necessary but is not the priority intervention.
Correct Answer is B
Explanation
The nurse should place the client's right leg in abduction following a right total hip arthroplasty. Abduction means moving the leg away from the midline of the body. This position helps to prevent hip dislocation by keeping the hip joint in proper alignment.
Internal rotation, adduction, and external rotation are not appropriate positions for the client's right leg following a right total hip arthroplasty. Internal rotation means turning the leg inward towards the midline of the body. Adduction means moving the leg towards the midline of the body. External rotation means turning the leg outward away from the midline of the body. These positions can increase the risk of hip dislocation.
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