A nurse is caring for a client who has a T4 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 states feeling hot and sweaty.
The client's bladder becomes distended.
The client's blood pressure becomes elevated.
The client reports having a severe headache.
The Correct Answer is B
A. Feeling hot and sweaty can occur during autonomic dysreflexia, but it is a symptom of the condition rather than a cause or risk factor.
B. Bladder distension is a common trigger for autonomic dysreflexia, a condition that occurs in individuals with spinal cord injuries at or above the T6 level, due to the excessive autonomic response to noxious stimuli such as a full bladder.
C. Elevated blood pressure is a sign of autonomic dysreflexia, but the risk factor to recognize is the underlying cause, such as bladder distension.
D. A severe headache is a symptom of autonomic dysreflexia, indicating the need for immediate action, but it is not a risk factor for developing the condition.
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Correct Answer is D
Explanation
A. Decreasing the client's oral fluid intake is inappropriate in the postoperative period following a TURP, as adequate hydration is essential to prevent clot formation and maintain catheter patency. Limiting fluids could lead to increased clot formation and obstructed flow.
B. Weighing the client every evening is not a relevant intervention in the immediate postoperative period of TURP. Weight monitoring is more critical for fluid balance in chronic conditions such as heart failure or renal disease, not in the acute setting after TURP.
C. Monitoring urine output every 6 hours is insufficient for a client receiving continuous bladder irrigation. Immediate postoperative care requires more frequent monitoring to detect potential complications such as clot retention or hemorrhage.
D. Reminding the client that he might feel a constant urge to void is essential. Continuous bladder irrigation can cause bladder spasms and a persistent sensation of needing to urinate, which is common after TURP. This helps the client understand and cope with these sensations, reducing anxiety and unnecessary concern.
Correct Answer is C
Explanation
A. Corticosteroids are not typically associated with causing thrombocytopenia. Their primary effects are on the immune system and metabolism.
B. Corticosteroids more commonly cause hypertension due to fluid retention and increased sensitivity to vasoconstrictors, rather than hypotension.
C. Corticosteroids cause immunosuppression by inhibiting the function of various immune cells and reducing the production of inflammatory cytokines. This increases the risk of infections.
D. Anemia is not a direct effect of corticosteroid use. The medication's impact on the bone marrow typically affects the white blood cell count, particularly in causing leukocytosis, rather than leading to anemia.
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