The nurse documents an abnormal finding from the Babinski reflex as a (the):

A. Check the client for a fecal impaction.

This intervention is important for managing autonomic dysreflexia because a fecal impaction can trigger autonomic dysreflexia by causing rectal distention. However, it is not the first action the nurse should take. Promptly addressing the immediate cause of autonomic dysreflexia is crucial to prevent complications.

B. Ensure the room temperature is warm.

This intervention is important for maintaining the client's comfort and preventing temperature-related complications. However, it is not the first action the nurse should take when suspecting autonomic dysreflexia. Immediate interventions to address the underlying cause of autonomic dysreflexia are necessary to prevent serious complications such as stroke or seizure.

C. Check the client's bladder for distention.

This is the correct action to take first. Bladder distention is one of the most common triggers of autonomic dysreflexia in individuals with spinal cord injuries. A distended bladder stimulates autonomic reflexes, leading to a sudden increase in blood pressure. Therefore, the nurse should assess the client's bladder for distention and initiate appropriate interventions such as catheterization to relieve urinary retention.

D. Raise the head of the bed.

While elevating the head of the bed can help reduce blood pressure in some situations, it is not the first action the nurse should take when suspecting autonomic dysreflexia. Elevating the head of the bed may exacerbate autonomic dysreflexia by increasing venous return and blood pressure. Therefore, addressing the underlying cause of autonomic dysreflexia, such as bladder distention, takes priority.

A. 4 hours:

This option indicates that tissue plasminogen activator (tPA) must be administered within 4 hours of the onset of stroke symptoms to be considered as a drug therapy option. tPA is a thrombolytic medication used to dissolve blood clots in ischemic stroke, and its effectiveness is highest when administered promptly after the onset of symptoms.

B. 1 hour:

Administering tPA within 1 hour of stroke onset would be extremely challenging and impractical. It typically takes time for patients to recognize stroke symptoms, seek medical attention, and undergo diagnostic evaluations before tPA administration. While time is of the essence in stroke treatment, 1 hour is too short of a timeframe for most patients to receive tPA.

C. 24 hours:

Administering tPA beyond 4.5 hours of stroke onset is generally contraindicated due to the increased risk of complications, including hemorrhagic transformation of the stroke. While there may be some extended time windows considered for certain patients under specific circumstances, such as those meeting eligibility criteria for extended thrombolytic therapy, 24 hours is outside the standard timeframe for tPA administration.

D. 8 hours:

While tPA administration within 8 hours of stroke onset may be feasible for some patients, it is beyond the standard recommended time window for optimal effectiveness. As mentioned earlier, tPA is most effective when administered within the first 3 to 4.5 hours after the onset of symptoms, with earlier administration associated with better outcomes.