A patient diagnosed with a spinal cord injury experienced spinal shock lasting 15 days. The patient is now experiencing an uncompensated cardiovascular response to sympathetic stimulation. What does the nurse suspect caused this condition?
Pain stimulation above the level of the spinal cord lesion
Toxic accumulation of free radicals below the level of the injury
A distended bladder or rectum
An abnormal vagal response
The Correct Answer is C
Choice A reason: Pain stimulation above the level of the spinal cord lesion can cause discomfort and an increase in sympathetic activity, but it is not the primary cause of an uncompensated cardiovascular response seen in autonomic dysreflexia. This condition typically results from stimuli below the level of the injury.
Choice B reason: Toxic accumulation of free radicals below the level of the injury can contribute to tissue damage and inflammation but is not the primary cause of the acute cardiovascular responses in autonomic dysreflexia. The condition is primarily triggered by noxious stimuli below the level of the injury.
Choice C reason: A distended bladder or rectum is a common cause of autonomic dysreflexia in patients with spinal cord injuries above the T6 level. This condition involves an exaggerated autonomic response to stimuli below the level of the injury, resulting in severe hypertension, bradycardia, and other cardiovascular symptoms. The distention of the bladder or rectum sends signals that the spinal cord cannot properly process, leading to an uncontrolled sympathetic response.
Choice D reason: An abnormal vagal response typically involves parasympathetic activity and can lead to symptoms such as bradycardia or fainting. However, it is not the primary cause of the sympathetic overactivity and hypertension seen in autonomic dysreflexia. The condition is driven by an imbalance in the autonomic nervous system due to spinal cord injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Hypernatremia (high sodium levels) is not typically associated with ACE inhibitors like enalapril. These medications do not significantly affect sodium levels in the body.
Choice B reason: Hypokalemia (low potassium levels) is not a common concern with ACE inhibitors. In fact, these medications can sometimes cause the opposite effect, leading to higher potassium levels.
Choice C reason: Hypertension (high blood pressure) is the condition that ACE inhibitors like enalapril are prescribed to treat. While monitoring blood pressure is important, it is not the specific concern related to potassium levels.
Choice D reason: Hyperkalemia (high potassium levels) is a significant concern for patients taking ACE inhibitors like enalapril. These medications can increase potassium levels in the blood, which can lead to serious complications such as cardiac arrhythmias. Therefore, patients need to be monitored carefully for signs of hyperkalemia, and their potassium levels should be checked regularly.
Correct Answer is C
Explanation
Choice A reason: Seizures with auras can involve symptoms such as sensory disturbances before the seizure event, but they do not typically present with fever, nuchal rigidity (stiff neck), or decreased consciousness. These symptoms suggest an infectious or inflammatory process, not a seizure disorder.
Choice B reason: Parkinson's disease is a neurodegenerative disorder characterized by tremors, stiffness, and bradykinesia (slowness of movement). It does not present with acute fever, headache, nuchal rigidity, or altered consciousness, nor is it associated with a history of sinusitis. The symptoms described are more indicative of an infectious condition rather than a chronic degenerative disease.
Choice C reason: Bacterial meningitis is an infection of the protective membranes covering the brain and spinal cord (meninges). It is characterized by symptoms such as fever, severe headache, nuchal rigidity, and altered consciousness. The history of sinusitis suggests a possible route of infection, as bacteria from the sinuses can spread to the meninges. The clinical presentation strongly supports the diagnosis of bacterial meningitis, which is a medical emergency requiring prompt treatment.
Choice D reason: Migraines can cause severe headaches and may be accompanied by nausea, vomiting, and sensitivity to light and sound. However, they do not typically cause fever, nuchal rigidity, or decreased consciousness. The presence of fever and neck stiffness suggests an infectious etiology rather than a primary headache disorder like migraines.
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