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 D
Explanation
Choice A reason: Liver cirrhosis is characterized by chronic liver damage leading to scarring and liver failure. The typical lab findings for liver cirrhosis would include elevated liver enzymes (ALT, AST), bilirubin, and low albumin levels, which are not mentioned in the given test results.
Choice B reason: Acute hepatitis refers to the inflammation of the liver, usually caused by viral infections or toxins. Lab results consistent with acute hepatitis would show elevated liver enzymes (ALT, AST) significantly higher than normal, which are not provided in the text.
Choice C reason: Cholecystitis is the inflammation of the gallbladder, often due to gallstones. Lab findings for cholecystitis may include elevated white blood cell count and sometimes mild elevation of liver enzymes, but not the specific elevated levels of serum amylase and lipase.
Choice D reason: Acute pancreatitis is an inflammation of the pancreas, and the hallmark lab findings include significantly elevated serum amylase and lipase levels. The test results show serum amylase of 920 units/L (reference: 30-220 units/L) and serum lipase of 704 units/L (reference: 0-160 units/L), which are highly indicative of acute pancreatitis. Elevated serum glucose and low serum calcium levels are also consistent with this diagnosis.
Correct Answer is D
Explanation
Choice A reason: Health care providers such as medical doctors (MDs) and nurse practitioners (NPs) are responsible for diagnosing and treating medical conditions. While they play a crucial role in patient care, the development of a detailed, individualized nursing plan of care typically falls under the domain of nursing professionals.
Choice B reason: Licensed practical/vocational nurses (LPNs/LVNs) provide basic patient care under the supervision of registered nurses and physicians. They assist with implementing care plans but do not usually develop comprehensive nursing plans of care themselves.
Choice C reason: Nursing supervisors oversee the nursing staff and ensure that nursing care is delivered effectively. They may be involved in developing and overseeing care plans at a higher level but are not typically responsible for creating the individualized care plans for each patient.
Choice D reason: Registered nurses (RNs) are trained and licensed to develop individualized care plans that include nursing diagnoses, interventions, and outcomes. They work closely with patients to create and implement care plans that address specific health needs and promote self-management.
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