The nurse is caring for a patient who has had a spinal cord injury at level C5-C6 as a result of an automobile accident. The patient suddenly develops severe hypertension, throbbing headache, blurred vision, and bradycardia.
What is the priority nursing intervention?
Administer antihypertensive medication as prescribed.
Elevate the head of bed to 90 degrees.
Check for bladder distention or fecal impaction.
Apply a cooling blanket to lower body temperature.
The Correct Answer is C
The correct answer is C.
Check for bladder distention or fecal impaction.
Autonomic dysreflexia is a disorder of autonomic nervous system dysregulation that occurs in patients with a spinal cord injury above T6.
It is caused by an exaggerated reflex response of the sympathetic nervous system due to an irritating stimulus below the spinal cord injury. It leads to severe hypertension and is a medical emergency.
Bladder or bowel distension are the most common triggers of autonomic dysreflexia.
Therefore, the priority nursing intervention is to check for bladder distention or fecal impaction and relieve them as soon as possible.
This can help to eliminate the stimulus and lower the blood pressure.
Choice A is wrong because administering antihypertensive medication as prescribed may not be effective or appropriate for autonomic dysreflexia.
The hypertension is caused by a reflex mechanism and not by a primary cardiovascular disorder. Moreover, antihypertensive drugs may cause hypotension once the stimulus is removed.
Choice B is wrong because elevating the head of bed to 90 degrees may not be enough to lower the blood pressure. It may also increase the risk of orthostatic hypotension once the stimulus is removed. However, sitting the patient upright and loosening any tight clothing are recommended as initial steps to reduce the blood pressure.
Choice D is wrong because applying a cooling blanket to lower body temperature is not indicated for autonomic dysreflexia. There is no evidence that body temperature is elevated or contributes to the hypertension in this condition. A cooling blanket may also cause vasoconstriction and worsen the hypertension.
Normal ranges for blood pressure vary depending on age, sex, and other factors.
However, a general guideline is that systolic blood pressure should be less than 120 mm Hg and diastolic blood pressure should be less than 80 mm Hg for most adults.
Normal ranges for heart rate also vary depending on age, activity level, and other factors.
However, a general guideline is that resting heart rate should be between 60 and 100 beats per minute for most adults.
References:.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A.
Dehydration.
Poor skin turgor means that the skin takes longer to return to its normal position after being pinched or pulled.
This is a sign of dehydration, which means the body does not have enough fluid.
Dehydration can be caused by not drinking enough water, vomiting, diarrhea, fever, diabetes, or other conditions that affect fluid balance.
Choice B is wrong because malnutrition does not directly affect skin turgor.
Malnutrition means the body does not get enough nutrients from food.
This can cause various problems, such as weight loss, muscle wasting, poor wound healing, and infections.
However, malnutrition does not cause the skin to lose its elasticity.
Choice C is wrong because loss of subcutaneous fat does not cause poor skin turgor.
Subcutaneous fat is the layer of fat under the skin that helps insulate the body and store energy.
As people age, they tend to lose some subcutaneous fat, especially in the face and hands.
This can make the skin look thinner and more wrinkled, but it does not affect how quickly the skin snaps back after being pinched.
Choice D is wrong because reduced collagen fibers do not cause poor skin turgor.
Collagen is a protein that gives the skin its strength and structure.
As people age, they produce less collagen, which can make the skin sag and lose firmness.
However, collagen does not affect the skin’s ability to retain water and return to its normal shape after being stretched.
Normal ranges for skin turgor vary depending on the age and location of the skin.
In general, healthy skin should return to its normal position within 2 seconds after being pinched.
In children and young adults, skin turgor can be tested on the abdomen or forearm.In elderly people, skin turgor can be tested on the clavicle (collar bone), sternum (breastbone), forehead, or inner thigh.These sites are less affected by skin wrinkling and aging.
Correct Answer is D
Explanation
You can do any of the above options, depending on your preference and medical condition.
Erectile dysfunction (ED) is the inability to get and maintain an erection for sexual activity.
It can be caused by physical or psychological factors, or both.
ED can affect your self-esteem, stress level and relationship quality.
There are different treatment options for ED, and they work in different ways.
Some of the most common ones are:.
• Oral medicationssuch as sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) or avanafil (Stendra).
These drugs enhance the effects of nitric oxide, a chemical that relaxes the muscles in the penis and increases blood flow.
You need to take them before sexual activity, and they only work if you are sexually stimulated.
They are not safe for everyone, especially if you have heart problems, low blood pressure, liver disease or certain eye conditions.They can also cause side effects such as headache, flushing, nasal congestion or indigestion.
• Penile self-injectionssuch as alprostadil (Caverject, Edex) or papaverine (OraVerse).
These are shots of medicine that you inject into the base or side of your penis with a fine needle.
They cause an erection by dilating the blood vessels in the penis.
The erection lasts about 20 to 30 minutes, and you need to use them only when needed.They can cause side effects such as bleeding, pain, priapism (a prolonged and painful erection) or fibrous tissue formation.
• Alprostadil urethral suppository(Muse).
This is a tiny pellet of medicine that you insert into your urethra (the tube that carries urine out of the body) with a special device.
It works by expanding the blood vessels in the penis and causing an erection.
The erection lasts about 30 to 60 minutes, and you need to use it only when needed.It can cause side effects such as burning, pain, bleeding or infection.
• Vacuum erection device(VED).
This is a plastic tube that you place over your penis and pump out the air to create a vacuum.
This draws blood into the penis and causes an erection.
You then slide a rubber ring around the base of your penis to keep the blood in place.
The erection lasts as long as the ring is on, up to 30 minutes.
You need to use it only when needed.It can cause side effects such as bruising, numbness, pain or difficulty ejaculating.
• Penile implant surgery.
This is a procedure where inflatable or bendable devices are surgically placed on both sides of your penis.
You can control when and how long you have an erection by inflating or deflating the devices with a pump or a switch.This is a permanent solution for ED, but it requires surgery and has risks of infection, mechanical failure or erosion.
Other treatment options for ED include hormone therapy, psychotherapy, lifestyle changes and natural remedies.
However, these may not be as effective or safe as the ones mentioned above.
The best treatment option for you depends on your personal preference, medical condition, cost and availability.
You should talk to your doctor about the benefits and risks of each option and choose the one that suits you best.
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