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.

Answer and Explanation

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:.

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Correct Answer is A

Explanation

The correct answer is A.

“I will use a walker until I can walk without pain.” This statement indicates a need for further teaching because the client should use a walker or other assistive device until they have regained their balance, flexibility and strength, not just until the pain subsides.Using a walker too long or too little can affect the healing process and the stability of the new hip joint.

Choice B is correct because the client should avoid crossing their legs or bending their hip more than 90 degrees to prevent dislocating the new hip joint.

Choice C is correct because the client should sleep on their back with a pillow between their legs to keep the hip in a neutral position and prevent excessive internal or external rotation.

Choice D is correct because the client should apply ice to their hip if it becomes swollen or inflamed to reduce pain and inflammation.The client should also elevate their leg and notify their healthcare provider if they notice any signs of infection, such as fever, chills, redness, warmth or drainage from the incision site.

Normal ranges for hip replacement surgery recovery vary depending on the individual and the type of surgery, but some general guidelines are:.

• The client should be able to walk with a cane or crutches within 2 to 4 weeks after surgery.

• The client should be able to resume most daily activities within 6 to 12 weeks after surgery.

• The client should avoid high-impact activities, such as running, jumping or contact sports, for at least 6 months after surgery.

• The client should have regular follow-up visits with their healthcare provider and physical therapist to monitor their progress and adjust their treatment plan as needed.

A. The client reports an improvement in mood, energy, appetite and sleep. B. The client scores lower on the Geriatric Depression Scale (GDS) or the Patient Health Questionnaire (PHQ-9). C. The client shows more interest and participation in social activities and hobbies. D. All of the above.

Correct Answer is D

Explanation

The correct answer is D.

All of the above.

This is because all of these findings indicate that the client has experienced an improvement in mood, energy, appetite, sleep, interest and participation in social activities and hobbies, which are common signs of depression recovery.

Choice A is wrong because it only covers some of the symptoms of depression, such as mood, energy, appetite and sleep, but not others, such as interest and participation in social activities and hobbies.

Choice B is wrong because it only measures the client’s depression level using standardized scales, such as the Geriatric Depression Scale (GDS) or the Patient Health Questionnaire (PHQ-9), but not their actual functioning and quality of life.

Choice C is wrong because it only reflects the client’s interest and participation in social activities and hobbies, which are important aspects of depression recovery, but not their mood, energy, appetite, sleep or depression level.

The GDS and the PHQ-9 are both valid and reliable tools for screening and measuring depression in older adults.

The GDS is a 15-item questionnaire that asks the client to answer yes or no to questions about their mood, satisfaction, hopelessness, helplessness, worthlessness, guilt, agitation, withdrawal and suicidal thoughts.

The PHQ-9 is a 9-item questionnaire that asks the client to rate how often they have experienced symptoms of depression in the past two weeks, such as depressed mood, anhedonia, insomnia or hypersomnia, fatigue, appetite or weight changes, concentration problems, feelings of worthlessness or guilt.

A. The client reports an improvement in mood, energy, appetite and sleep B.

The client scores lower on the Geriatric Depression Scale (GDS) or the Patient Health Questionnaire (PHQ-9) C.

The client shows more interest and participation in social activities and hobbies D.

All of the above

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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?

Nursing Test Bank

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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?