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 nurse should monitor the client for flank pain as an adverse effect of taking calcium carbonate. Calcium carbonate is a calcium supplement used to prevent or treat a calcium deficiency¹. One of the side effects of calcium carbonate is the formation of kidney stones, which can cause flank pain².
a. Urinary retention is not a common adverse effect of calcium carbonate.
b. Tinnitus is not a common adverse effect of calcium carbonate.
d. Bradycardia is not a common adverse effect of calcium carbonate.
Correct Answer is D
Explanation
a. Auscultation of lungs revealing wheezing is not related to venous return in the affected arm. Wheezing is
a high-pitched whistling sound made while breathing and is usually a sign of a respiratory problem.
b.A bounding distal pulse indicates strong arterial blood flow, which is not a sign of impaired venous return. Impaired venous return would more likely result in a weak or absent pulse.
c. Fever could indicate infection but is not specific to impaired venous return. It's a systemic sign that may or may not be related to the cast or the fracture.
d. Pain that is unrelieved by opioid analgesics can be a sign of compartment syndrome, which is a serious complication that can result from impaired venous return and increased pressure within the muscle compartments. This requires immediate medical attention to prevent permanent damage.
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