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.

Answer and Explanation

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. Absence of pulmonary and peripheral edema is not a primary goal of vasopressor therapy. The focus is on improving blood pressure and perfusion.
B. Vasopressor therapy aims to increase blood pressure, not reduce stroke volume or cardiac output.
C. Vasopressors are used to increase blood pressure, so reducing blood pressure is not an intended goal.
D. The primary goal of vasopressor therapy in septic shock is to maintain an adequate mean arterial pressure (MAP) to ensure adequate organ perfusion and prevent organ failure.

A. Dry the sclera with a cotton swab prior to medication administration. B. Administer the medications 5 minutes apart. C. Administer the medications by touching the tip of the dropper to the sclera of the eye. D. Hold pressure on the conjunctival sac for 2 minutes following application of drops.

Correct Answer is B

Explanation

A. Drying the sclera with a cotton swab prior to administering eye drops is not recommended and could introduce fibers or cause irritation. Proper eye drop administration does not require drying the sclera.
B. Administering the medications 5 minutes apart is correct because it allows each medication to be absorbed properly, preventing the second drop from washing out the first. This timing helps ensure that both medications are effective.
C. Touching the tip of the dropper to the sclera is incorrect and can introduce contaminants, leading to infection. Eye drops should be administered without the dropper touching the eye to maintain sterility.
D. Holding pressure on the conjunctival sac for 2 minutes is excessive. The recommended practice is to gently press on the nasolacrimal duct for 1-2 minutes after administration to prevent systemic absorption, especially with medications like timolol.

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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?

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Naxlex Comprehensive Predictor Exams

The critical care nurse is preparing to initiate an infusion of a vasopressor medication to a client in septic shock. What goal of this treatment should the nurse identify?

Correct Answer is D

Explanation

A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?

Correct Answer is B

Explanation

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