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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This is the correct answer because right-sided homonymous hemianopsia means that the client has lost vision in the right half of both eyes, so placing food trays on the left side of the client will help them see and access their food better.

Choice B reason: This is incorrect because placing food trays on the right side of the client will make it harder for them to see and reach their food, as they have no vision on that side.

Choice C reason: This is incorrect because performing a focused visual exam is not an appropriate action for the nurse to take during meal time. The nurse should assess the client's vision before or after meals, but not interfere with their eating.

Choice D reason: This is incorrect because having the assistive personnel feed all meals to the client will decrease their independence and dignity, as well as their ability to practice using their unaffected side. The nurse should encourage and assist the client to feed themselves as much as possible, and only provide assistance when needed.

A. Soft pasty stool is noted in the collection device B. There is purple discoloration of the stoma C. Stoma is beefy red D. There is skin excoriation around the stoma

Correct Answer is B

Explanation

Choice A Reason: Soft pasty stool is normal for a transverse colostomy, as the stool has not reached the sigmoid colon where most of the water is absorbed.

Choice B Reason: This is the correct answer because purple discoloration of the stoma indicates ischemia or necrosis, which can lead to infection, perforation, or sepsis. It requires urgent intervention.

Choice C Reason: Stoma is beefy red is a normal finding for a healthy stoma, as it indicates adequate blood supply and healing.

Choice D Reason: There is skin excoriation around the stoma is a common complication of a colostomy, as the stool can irritate the skin. It can be managed with proper skin care and appliance fitting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who recently suffered a stroke suffers from right-sided homonymous hemianopsia. What is the best action for the nurse to take when caring for the client during mealtime?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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