Your spinal cord injury (SCI) patient complains of a throbbing headache and nausea. You observe the patient has marked diaphoresis, and you think the patient may have autonomic dysreflexia. Place the following interventions in the order you would complete them.
Check the blood pressure
Obtain a bladder scan
Notify the doctor
Elevate the head of the bed to 45 degrees
The Correct Answer is D,A,B,C
Choice D reason: Elevating the head of the bed to 45 degrees is the first intervention the nurse should perform. This position helps lower the patient's blood pressure by promoting venous pooling in the lower extremities and reducing the return of blood to the heart. It also aids in better breathing and overall comfort.
Choice A reason: Checking the blood pressure is crucial in this situation to confirm if the patient is experiencing autonomic dysreflexia, which is characterized by a sudden and severe increase in blood pressure. This step helps in assessing the severity of the condition and guiding subsequent interventions.
Choice B reason: Obtaining a bladder scan is important because a full bladder is a common trigger of autonomic dysreflexia. By identifying and addressing the cause of the distension, the nurse can help alleviate the symptoms and prevent further complications.
Choice C reason: Notifying the doctor is a critical step, as autonomic dysreflexia is a medical emergency that requires prompt medical intervention. The healthcare provider can give additional orders and may administer medication to control the patient's blood pressure and relieve symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: The nurse would include making decisions about health and lifestyle modifications to manage MS because this helps the patient to make informed choices that can alleviate symptoms and improve their quality of life. Modifying aspects such as diet, exercise, and stress management can play a significant role in managing the disease and preventing relapses.
Choice B reason: Curing the disease is not currently a feasible outcome for multiple sclerosis, as there is no known cure. The focus of the care plan is typically on managing symptoms, slowing the progression of the disease, and improving the patient's quality of life rather than curing the disease.
Choice C reason: Maintaining or improving muscle strength and mobility is crucial for patients with MS, as the disease often affects muscle control and strength. Including this outcome in the care plan helps to reduce the risk of falls, improve the patient's ability to perform daily tasks, and enhance overall physical function.
Choice D reason: Maintaining urinary continence is an important aspect of care for MS patients, as the disease can affect bladder control. Including this outcome helps to ensure the patient's comfort and dignity, prevent urinary tract infections, and improve their quality of life.
Choice E reason: Maintaining independence in performing activities of daily living (ADLs) is essential for patients with MS to ensure they can continue to perform tasks such as bathing, dressing, and eating. This outcome supports the patient's self-esteem and promotes a sense of autonomy.
Correct Answer is B
Explanation
Choice A reason: Asking the patient to try bearing weight on the injured ankle is not appropriate at this stage. Bearing weight can cause further injury or exacerbate the swelling and pain. The initial treatment should focus on reducing swelling and providing support.
Choice B reason: Elevating the ankle above heart level is appropriate because it helps to reduce swelling by promoting venous return and decreasing fluid accumulation in the affected area. Elevation is a standard first aid measure for managing acute injuries and swelling.
Choice C reason: Applying a warm moist pack to the ankle is not advisable immediately after an injury. In the acute phase, cold therapy (ice) is recommended to reduce swelling and pain. Warm therapy is more appropriate during the recovery phase, once swelling has subsided.
Choice D reason: Assessing the ankle's passive range of motion (ROM) may be necessary later, but not immediately upon arrival. The priority is to manage pain and swelling first. ROM assessments can be painful and might worsen the injury if conducted too soon.
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