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 C

Explanation

A.Obtaining a throat culture specimen might be necessary if a throat infection is suspected, but it is not the immediate priority without first assessing the presence of fever or other systemic signs.
B. Performing a complete blood count could be useful in diagnosing underlying conditions or infections but is not the initial action; the temperature check provides immediate information about potential systemic infection.

C.Check the client's temperature.Headache and stiff neck are symptoms that could be associated with various conditions, including infections such as meningitis. A fever often accompanies infections, and checking the client's temperature helps in identifying if there is a fever, which could be indicative of an infection requiring further evaluation and treatment.

D. Administering an oral analgesic could provide symptom relief but does not address the underlying cause of the symptoms. It is essential first to assess the client’s condition fully before initiating symptomatic treatment.

A. Check the client for injuries. B. Obtain a prescription for medication to sedate the client. C. Call the family and ask them to make arrangements for someone to sit with the client. D. Assist the client back into bed and apply restraints.

Correct Answer is A

Explanation

The first action the nurse should take is to check the client for injuries. The nurse should assess the client for any signs of injury or trauma and provide appropriate care as needed.

Obtaining a prescription for medication to sedate the client, calling the family and asking them to make arrangements for someone to sit with the client, and assisting the client back into bed and applying restraints are not appropriate initial actions for the nurse to take in this situation. These actions may be considered after the client has been assessed for injuries and their immediate needs have been addressed.

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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?

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Naxlex Comprehensive Predictor Exams

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