The nurse observing a client with autonomic dysreflexia would expect which of the following clinical manifestations?

Tachycardia and hypertension

Bradycardia and hypertension

Bradycardia and hypotension

Tachycardia and hypotension

Answer and Explanation

The Correct Answer is B

A. Tachycardia does not occur with autonomic dysreflexia.

B. Autonomic dysreflexia is a life-threatening condition caused by a noxious stimulus (e.g., full bladder, constipation) in patients with spinal cord injuries above T6. It leads to severe hypertension and reflex bradycardia.

C. Hypotension is not a symptom; autonomic dysreflexia causes hypertension.

D. Tachycardia and hypotension are more associated with spinal shock rather than autonomic dysreflexia.

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Correct Answer is B

Explanation

A. Give potassium intravenously. – The potassium level is 3.7 (within normal range 3.5–5.0), so potassium is not needed yet.

B. Administer D5 NS with the insulin drip. – Correct Answer. Once glucose drops to ≤200 mg/dL, dextrose is added to prevent hypoglycemia while continuing insulin to correct ketoacidosis.

C. Administer 3% NS at 200 mL/hr. – Hypertonic saline is used for severe hyponatremia, which is not the case here.

D. Expect the insulin drip to be discontinued. – The insulin drip is not discontinued until ketoacidosis has fully resolved (when HCO3 > 18, pH > 7.3, and anion gap normalizes).

A. suggest the visitors stay a bit longer to provide support and distraction. B. suggest the patient ambulates in the hallway to become fatigued, so they can rest. C. turn the lights and television off except for a night light. D. turn on the television to be used as a distractor for the patient.

Correct Answer is C

Explanation

A. Suggest the visitors stay a bit longer to provide support and distraction. – Noise and stimulation can worsen migraines.

B. Suggest the patient ambulates in the hallway to become fatigued, so they can rest. – Movement may increase pain.

C. Turn the lights and television off except for a night light. – Correct Answer. Migraines are worsened by light and noise, so a dark and quiet environment is best.

D. Turn on the television to be used as a distractor for the patient. – Bright lights and sound can aggravate symptoms.

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The nurse observing a client with autonomic dysreflexia would expect which of the following clinical manifestations?

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