Exhibits

The nurse is stabilizing the client and preparing her for surgery.
Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.

Choice A reason: Hypotension and venous pooling in the extremities are typically signs of neurogenic shock, which occurs immediately after a spinal cord injury. However, autonomic dysreflexia is characterized by severe hypertension, not hypotension. The symptoms in this scenario do not fit the presentation of autonomic dysreflexia.

Choice B reason: Reports of chest pain and shortness of breath are not the primary symptoms of autonomic dysreflexia. While autonomic dysreflexia can cause a variety of symptoms due to uncontrolled sympathetic nervous system activity, the hallmark symptoms are severe hypertension and headache, along with other specific signs like diaphoresis.

Choice C reason: Pain and a burning sensation upon urination and hematuria indicate a urinary tract infection or another urological issue, not autonomic dysreflexia. While a full bladder is a common trigger for autonomic dysreflexia, the symptoms described in this choice do not accurately reflect the condition.

Choice D reason: Profuse diaphoresis and a severe, pounding headache are classic symptoms of autonomic dysreflexia. This condition results from an overactive autonomic nervous system response to stimuli below the level of the injury, such as a full bladder. The resulting vasoconstriction leads to severe hypertension and symptoms like headache and sweating above the level of injury.

Choice A reason: Administering medications as prescribed is a critical intervention for this client experiencing an acute asthma exacerbation. The prescribed medications, including albuterol and ipratropium bromide via nebulizer, act to relieve bronchospasm and improve airflow. Albuterol, a beta-2 adrenergic agonist, works by relaxing smooth muscles in the airway, while ipratropium, an anticholinergic, reduces mucus production and further enhances bronchodilation. Prednisone, a corticosteroid, reduces airway inflammation and prevents progression of the attack. Administering these medications promptly addresses the underlying pathophysiology of the asthma attack, improves oxygenation, and reduces the risk of complications like hypoxemia or respiratory failure. This is an essential and time-sensitive step in the client’s care.

Choice B reason: Providing client teaching is essential to address both immediate and long-term care needs. Education should focus on the correct use of inhalers, the importance of monitoring expiration dates, and adherence to prescribed medications. The nurse should explain proper inhalation techniques, the role of maintenance medications in preventing exacerbations, and the importance of identifying and avoiding triggers such as outdoor allergens and exercise without premedication. Additionally, discussing early signs of asthma worsening and when to seek medical attention can empower the client to better manage their condition and prevent severe exacerbations in the future. This intervention ensures the client has the tools to reduce recurrence and improve quality of life.

Choice C reason: Notifying the healthcare provider of the client's need for intubation is unnecessary at this stage based on the assessment data. While the client is in respiratory distress, indicated by increased respiratory rate and low oxygen saturation, they remain alert and responsive, with expiratory wheezes present—a sign that air is moving through the lungs. Intubation is reserved for clients in severe respiratory failure who are unable to maintain oxygenation or ventilation despite aggressive interventions. Administering nebulized medications and corticosteroids should stabilize the client and resolve the acute symptoms, making this action premature and inappropriate.

Choice D reason: Placing the client in the Trendelenburg position is contraindicated in asthma management and respiratory distress. The Trendelenburg position involves lowering the head of the bed and elevating the feet, which could worsen breathing by increasing pressure on the diaphragm, reducing lung expansion, and exacerbating hypoxemia. The preferred position for clients in respiratory distress is a high Fowler’s position, which promotes optimal lung expansion and improves oxygenation. The Trendelenburg position is used for specific conditions like shock or hypotension but has no role in managing asthma exacerbations.

Choice E reason: Asking the client for a list of current medications is a vital step in obtaining an accurate medication history and identifying potential factors contributing to the asthma exacerbation. An expired rescue inhaler suggests possible gaps in medication adherence or management. Understanding the client’s current medications, including any maintenance inhalers or allergy treatments, helps the healthcare team adjust the treatment plan effectively. Additionally, this step ensures that new prescriptions do not conflict with existing medications, reducing the risk of adverse interactions. It also highlights any missed preventive measures, such as maintenance therapy with inhaled corticosteroids, which can significantly reduce the frequency and severity of asthma attacks.