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.

Assess the client for bladder distention.

Obtain the client's heart rate.

Place the client in a high-Fowler's position.

Answer and Explanation

The Correct Answer is D

Prioritizing interventions for autonomic dysreflexia in quadriplegic clients requires understanding the physiological response to noxious stimuli below the injury level. Critical thinking is applied to determine the most immediate action to lower dangerous hypertensive levels and prevent intracranial hemorrhage or seizures.

Choice A rationale

Nitrates are used to manage severe hypertension in autonomic dysreflexia, but pharmacological intervention is not the first step. Non-pharmacological measures to reduce blood pressure should be attempted immediately before administering medications to the client to ensure safety.

Choice B rationale

Assessing for bladder distention is vital because it is the most common trigger for autonomic dysreflexia. However, physiological stabilization via positioning must occur before or simultaneously with the search for the underlying cause to prevent immediate vascular complications.

Choice C rationale

Monitoring the heart rate is necessary as bradycardia often accompanies the hypertensive surge in autonomic dysreflexia. While important for assessment, obtaining vital signs does not actively lower the blood pressure or address the immediate risk of a stroke.

Choice D rationale

Placing the client in a high-Fowler's position is the priority action because it utilizes gravity to cause orthostatic pooling of blood in the lower extremities. This immediate intervention helps decrease the dangerously high blood pressure and reduces intracranial pressure..

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Correct Answer is A

Explanation

Hyperkalemia management involves identifying medications that facilitate the removal of potassium from the body. Understanding the mechanism of action of various renal and GI medications is necessary. This prevents cardiac arrest by lowering potassium toward the 3.5 to 5.0 mEq/L range.

Choice A rationale

This medication is a cation exchange resin that works in the intestine. It exchanges sodium ions for potassium ions, allowing the potassium to be excreted through the feces. It is specifically indicated for treating high serum potassium levels.

Choice B rationale

Lactulose is an osmotic laxative primarily used to reduce serum ammonia levels in clients with hepatic encephalopathy. It promotes the excretion of ammonia through the stool but has no significant effect on lowering serum potassium levels.

Choice C rationale

This medication is an erythropoiesis stimulating agent used to treat anemia associated with chronic kidney disease. It stimulates red blood cell production in the bone marrow but does not influence electrolyte levels or treat acute hyperkalemia.

Choice D rationale

Sevelamer is a phosphate binder used to manage hyperphosphatemia in clients with chronic kidney disease. It prevents the absorption of dietary phosphorus in the gut but does not have a mechanism to lower serum potassium concentrations.

A. Mean arterial pressure (MAP), cardiac output (CO), and pulmonary artery pressure (PAP). B. Pulmonary artery pressure (PAP), pulmonary artery wedge pressure (PAWP), and cardiac output (CO). C. Mean arterial pressure (MAP), central venous pressure (CVP), and systemic vascular resistance (SVR). D. Cardiac output (CO), stroke volume (SV), and systemic vascular resistance (SVR).

Correct Answer is B

Explanation

Monitoring critical illness requires understanding hemodynamic monitoring through invasive catheters. Knowledge of cardiovascular physiology and the specific capabilities of the Swan-Ganz catheter is necessary to distinguish between parameters that are directly measured versus those calculated via mathematical hemodynamic formulas.

Choice A rationale

Pulmonary artery catheters do not measure mean arterial pressure, which requires a peripheral arterial line. PAP and CO are measured, but the inclusion of MAP makes this choice incorrect as it assesses systemic rather than pulmonary hemodynamics.

Choice B rationale

This catheter sits in the pulmonary artery, allowing direct measurement of systolic, diastolic, and mean PAP. Inflation of the balloon allows measurement of PAWP, while thermistor technology enables the direct calculation of cardiac output via thermodilation.

Choice C rationale

Central venous pressure is measured via the proximal port of the catheter, but MAP and SVR are not direct measurements. SVR is a calculated value derived from MAP, CVP, and CO using a mathematical formula.

Choice D rationale

While cardiac output is measured directly, stroke volume and systemic vascular resistance are calculated parameters. Stroke volume is determined by dividing cardiac output by heart rate, while SVR utilizes the pressure gradient across the systemic circuit.

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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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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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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?