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 D
Explanation
Choice A Reason: This is incorrect because dimming the lights in the client's room is not a helpful action for providing discharge teaching for a client who has hearing loss. Dimming the lights can reduce the visibility and clarity of the nurse's facial expressions, gestures, and lip movements, which can aid in communication.
Choice B Reason: This is incorrect because increasing the rate of speech when talking with the client is not an effective action for providing discharge teaching for a client who has hearing loss. Increasing the rate of speech can make it harder for the client to follow and understand what the nurse is saying.
Choice C Reason: This is incorrect because answering client's questions using medical terminology is not an appropriate action for providing discharge teaching for a client who has hearing loss. Medical terminology can be confusing and unfamiliar to the client, which can impair comprehension and learning.
Choice D Reason: This is the correct choice because facing the client while talking is an important action for providing discharge teaching for a client who has hearing loss. Facing the client can enhance eye contact, attention, and rapport. It can also allow the client to see the nurse's facial expressions, gestures, and lip movements, which can facilitate communication.
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