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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A: Eliciting the gag reﬂex is a way to assess cranial nerve IX (glossopharyngeal) and X (vagus), which are responsible for the sensation and motor function of the pharynx and larynx.

Choice B: Testing visual acuity is a way to assess cranial nerve II (optic), which is responsible for the sense of vision.

Choice C: Observing for facial symmetry is a way to assess cranial nerve VII (facial), which is responsible for the motor function of the facial muscles and the sensation of taste.

Choice D: Checking the pupillary response to light is a way to assess cranial nerve III (oculomotor), which is responsible for the motor function of most of the eye muscles, including those that control pupil size and lens shape.

A. Right ventricular failure B. Fluid volume deficit C. Mitral regurgitation D. Afterload reduction

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because right ventricular failure would cause an increase in right atrial pressure and right ventricular end-diastolic pressure, but not in PAWP, which reﬂects left atrial pressure and left ventricular end- diastolic pressure.

Choice B Reason: This is incorrect because ﬂuid volume deficit would cause a decrease in PAWP, as there would be less blood volume in the pulmonary circulation.

Choice C Reason: This is correct because mitral regurgitation would cause an increase in PAWP, as the blood would back up into the left atrium and pulmonary veins due to the incompetent mitral valve.

Choice D Reason: This is incorrect because afterload reduction would cause a decrease in PAWP, as there would be less resistance to the left ventricular ejection and less blood volume in the pulmonary circulation.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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