A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?
The client's bladder becomes distended.
The client states having a severe headache.
The client's blood pressure becomes elevated.
The client states having nasal congestion.
Correct Answer : A,B,C,D
Choice A Reason: A distended bladder is one of the most common triggers of autonomic dysreflexia, which is a life-threatening condition that occurs in clients with spinal cord injuries above T-6. The bladder becomes overfilled and stimulates the sympathetic nervous system, causing vasoconstriction and hypertension.
Choice B Reason: A severe headache is one of the most common symptoms of autonomic dysreflexia, caused by the increased blood pressure in the brain. The headache may be accompanied by blurred vision, sweating, flushing, or anxiety.
Choice C Reason: An elevated blood pressure is the hallmark sign of autonomic dysreflexia, which can reach dangerously high levels and cause stroke, seizure, or death. The blood pressure may rise up to 300/160 mmHg or higher.
Choice D Reason: Nasal congestion is another possible trigger of autonomic dysreflexia, as it stimulates the nasal mucosa and activates the sympathetic nervous system. Other potential triggers include bowel impaction, skin irritation, tight clothing, or temperature changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because bacterial meningitis is a medical emergency that requires immediate antibiotic therapy to prevent complications and death.
Choice B reason: This is incorrect because documenting intake and output is not a priority action for a child with bacterial meningitis. Fluid balance is important, but not as urgent as antibiotic administration.
Choice C reason: This is incorrect because reducing environmental stimuli is a supportive measure that can help reduce headache and photophobia, but it is not a priority action for a child with bacterial meningitis. The nurse should focus on preventing infection spread and monitoring for signs of increased intracranial pressure.
Choice D reason: This is incorrect because maintaining seizure precautions is a preventive measure that can help protect the child from injury, but it is not a priority action for a child with bacterial meningitis. The nurse should administer anticonvulsants as prescribed and observe for seizure activity, but the main goal is to treat the infection.
Correct Answer is B
Explanation
Choice A Reason: A virus is not detected by the KOH test, which is used to diagnose fungal infections of the skin, hair, or nails. A virus can be detected by other tests, such as polymerase chain reaction (PCR) or viral culture.
Choice B Reason: A fungal infection is detected by the KOH test, which dissolves the skin cells and leaves behind the fungal elements that can be seen under a microscope. A fungal infection can cause symptoms such as itching, scaling, redness, or blisters.
Choice C Reason: A bacterial infection is not detected by the KOH test, which is specific for fungi. A bacterial infection can be detected by other tests, such as gram stain or culture.
Choice D Reason: Cancer is not detected by the KOH test, which is not a screening tool for malignancy. Cancer can be detected by other tests, such as biopsy or imaging.
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