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 A

Explanation

A. A decrease in the Glasgow Coma Scale score from 13 to 10 indicates a significant change in consciousness and may suggest worsening of the brain injury. This is a critical sign that requires immediate reporting and evaluation.
B. Diplopia (double vision) can be a concerning symptom, but it is not as immediately critical as a significant change in the Glasgow Coma Scale score. It still warrants attention but may not be the highest priority.
C. Ataxia (lack of voluntary coordination of muscle movements) is a serious symptom that could indicate worsening of the brain injury but is not as immediately critical as a significant change in the Glasgow Coma Scale score.
D. A drop in heart rate from 76 to 70/min is generally not significant in the context of mild TBI. Changes in heart rate are less critical compared to changes in the level of consciousness.

A. Place the client on protective isolation. B. Initiate measures to prevent venous thromboembolism. C. Initiate droplet precautions. D. Check the client's most recent platelet level.

Correct Answer is D

Explanation

A. Protective isolation is not directly related to the symptoms of ecchymoses and petechiae but is more relevant for preventing infections in immunocompromised clients.
B. Measures to prevent venous thromboembolism are not the immediate concern given the bleeding symptoms; instead, managing platelet levels and bleeding risks is more critical.
C. Droplet precautions are not indicated based on the described symptoms, which are more related to bleeding disorders rather than infectious conditions requiring droplet precautions.
D. Checking the client's most recent platelet level is the most appropriate action because ecchymoses and petechiae are signs of potential thrombocytopenia (low platelet count), which is common in leukemia. Monitoring platelet levels will help determine if there is a need for interventions to address bleeding risks.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations is the priority for the nurse to report to the healthcare provider?

Correct Answer is A

Explanation

A nurse is caring for a client who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the client's sacral area and petechiae on the forearms. Based on the most recent assessment findings, the nurse should perform which action?

Correct Answer is D

Explanation

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