The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

Elevate the head of the bed, loosen clothing, and check the urinary catheter for obstruction

Elevate the head of the bed and apply a cool compress to the forehead

Place in Semi-Fowler's position and establish IV access

Establish IV access, apply 2 liters of nasal oxygen, and contact the health care provider

Answer and Explanation

The Correct Answer is A

A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.

B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.

C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.

D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.

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Correct Answer is D

Explanation

A. Posterior cord injury usually affects proprioception rather than causing a distinctive pattern of motor and sensory loss.

B. Anterior cord injury generally impacts motor function and temperature and pain sensation bilaterally, not in a hemisection pattern.

C. Central cord injury primarily affects motor function in the upper extremities and is not characterized by ipsilateral motor and contralateral sensory loss.

D. Brown-Sequard syndrome typically presents with motor function loss on the same (ipsilateral) side of the injury and loss of pain and temperature sensation on the opposite (contralateral) side, making this the most likely diagnosis.

Correct Answer is ["3"]

Explanation

To administer the correct dose of clonidine, which is 0.3 mg, the nurse would need to calculate the number of 0.1 mg tablets required. Since each tablet contains 0.1 mg of clonidine, the nurse would need three tablets to make up the total dose of 0.3 mg. Therefore, the nurse should administer three tablets per dose to the patient.

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The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is preparing to administer clonidine 0.3 mg at bedtime to a patient. The amount available is clonidine 0.1 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["3"]

Explanation

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