A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?
Administer a nitrate antihypertensive.
Obtain the client's heart rate.
Assess the client for bladder distention.
Place the client in a high-Fowler's position.
The Correct Answer is D
Choice A Reason: This is incorrect because administering a nitrate antihypertensive is not the first action, as it may cause a rapid drop in blood pressure and worsen the client's condition.
Choice B Reason: This is incorrect because obtaining the client's heart rate is not the first action, as it does not address the cause of autonomic dysreflexia or relieve the symptoms.
Choice C Reason: This is incorrect because assessing the client for bladder distention is not the first action, as it may take time and delay the treatment of autonomic dysreflexia.
Choice D Reason: This is correct because placing the client in a high-Fowler's position is the first action, as it lowers the blood pressure by promoting venous return and reducing cardiac preload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Packed RBCs are indicated for clients who have hypovolemic shock due to blood loss, as they increase the oxygen-carrying capacity of the blood and restore the blood volume.
Choice B Reason: Cryoprecipitates are indicated for clients who have hemophilia or von Willebrand disease, as they contain clotting factors that help stop bleeding.
Choice C Reason: Albumin is indicated for clients who have hypovolemic shock due to fluid loss, such as from burns or ascites, as it increases the plasma oncotic pressure and draws fluid into the vascular space.
Choice D Reason: Platelets are indicated for clients who have thrombocytopenia or platelet dysfunction, as they help prevent or control bleeding.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because hypervolemia is a condition of excess fluid volume in the body. A client who has an extensive burn injury is more likely to have hypovolemia, which is a condition of low fluid volume, due to fluid loss from the damaged skin and capillaries.
Choice B Reason: This is incorrect because metabolic alkalosis is a condition of high blood pH and high bicarbonate level. A client who has an extensive burn injury is more likely to have metabolic acidosis, which is a condition of low blood pH and low bicarbonate level, due to increased production of lactic acid and ketones from tissue hypoxia and breakdown.
Choice C Reason: This is correct because low hemoglobin is a common laboratory finding in a client who has an extensive burn injury. Hemoglobin is the protein in red blood cells that carries oxygen. A client who has an extensive burn injury may have low hemoglobin due to hemolysis, which is the destruction of red blood cells, or hemorrhage, which is the loss of blood.
Choice D Reason: This is incorrect because hyperkalemia is a condition of high blood potassium level. A client who has an extensive burn injury may have hyperkalemia in the early phase of injury, due to cell damage and potassium release, but it is usually transient and followed by hypokalemia, which is a condition of low blood potassium level, due to fluid loss and potassium depletion.
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