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: To calculate the total body surface area (TBSA) affected by burns using the Rule of Nines, the body is divided into sections, each representing a percentage of TBSA:
- Front of one leg = 9%
- Back of one leg = 9%
- Front of one arm = 4.5%
- Back of one arm = 4.5%
Now for the calculation:
-
Both legs (front and back):
- Front of both legs = 9% × 2 = 18%
- Back of both legs = 9% × 2 = 18%
- Total for both legs = 18% + 18% = 36%
-
Both arms (front and back):
- Front of both arms = 4.5% × 2 = 9%
- Back of both arms = 4.5% × 2 = 9%
- Total for both arms = 9% + 9% = 18%
-
Total TBSA:
- Legs (36%) + Arms (18%) = 54%
The nurse should document burns to 54% of the client's total body surface area (TBSA).
Choice B Reason:This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.
Choice C Reason: This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.
Choice D Reason: This choice is incorrect because it uses a random percentage that does not correspond to any rule or calculation.
Correct Answer is D
Explanation
Choice A Reason: This choice is incorrect because slowing the rate to 50 mL/hr may not be enough to prevent cerebral edema, which is a common complication of head injury. Cerebral edema is a swelling of the brain tissue due to increased fluid accumulation. It can cause increased intracranial pressure (ICP), which can lead to brain damage or death. Therefore, the nurse should limit the fluid intake of the client with head injury to avoid worsening the condition.
Choice B Reason: This choice is incorrect because increasing the rate to 250 mL/hr may cause fluid overload, which can also increase the ICP and worsen the cerebral edema. Fluid overload is a condition in which the body has too much fluid, which can impair the function of the heart, lungs, and kidneys. Therefore, the nurse should avoid giving too much fluid to the client with head injury.
Choice C reason: Reducing the infusion to 20 mL/hr is excessively low and may cause hypotension or inadequate maintenance of vascular access and medication delivery. Such a drastic decrease could impair perfusion to injured brain tissue and is not an appropriate independent nursing action without a specific order.
Choice D reason: Maintaining the current prescribed infusion rate avoids abrupt volume shifts that could alter intracranial pressure. The nurse should monitor neurologic status and vital signs, ensure the IV is patent, and follow provider orders; only change the rate when clinically indicated or when directed by the prescriber.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today