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 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.

A. "I should include foods high in protein, like fish and chicken." B. "I should avoid foods such as low-fat dairy products." C. "I should include foods high in carbohydrates, like pie and donuts." D. "I should avoid foods high in fat, like fried chicken."

Correct Answer is D

Explanation

A. Foods high in protein, like fish and chicken, are generally recommended in a low-fat diet but are not specific to managing biliary colic.
B. Low-fat dairy products are usually recommended as part of a low-fat diet and are not typically avoided for cholecystitis.
C. High-carbohydrate foods like pie and donuts are not advised for general health but are not specifically targeted for managing biliary colic.
D. Avoiding foods high in fat, such as fried chicken, is important for managing biliary colic and chronic cholecystitis. Fatty foods can stimulate gallbladder contractions and exacerbate symptoms.

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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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