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 C
Explanation
Choice A reason: Weight gain is not commonly associated with Parkinson's disease. In fact, patients with PD often experience weight loss due to increased energy expenditure from tremors and muscle rigidity, as well as difficulties with eating.
Choice B reason: Cardiovascular problems are not directly caused by Parkinson's disease. While PD patients may have cardiovascular issues, these are typically related to age or other comorbid conditions rather than PD itself.
Choice C reason: Swallowing challenges, or dysphagia, are a significant concern for patients with Parkinson's disease. The motor symptoms of PD, including muscle rigidity and bradykinesia, can affect the muscles involved in swallowing, leading to difficulty eating and an increased risk of aspiration and choking. Addressing swallowing challenges is crucial for maintaining nutrition and preventing respiratory complications.
Choice D reason: Obesity is not a typical issue for patients with Parkinson's disease. As mentioned earlier, weight loss is more common due to the disease's impact on motor function and the effort required for daily activities.
Correct Answer is C
Explanation
Choice A reason: Amber fluid is typically a sign of serous exudate, which is a normal part of the inflammatory process and wound healing. It indicates the body's immune response to the injury and is generally not a cause for concern unless the volume significantly increases or changes in appearance.
Choice B reason: Clear drainage, or serous fluid, is also a normal finding in wound healing. It indicates that the wound is exuding plasma, which helps to keep the wound moist and supports the healing process. This type of drainage is typically not worrisome unless there are other signs of infection or complications.
Choice C reason: Purulent, draining wound is a major concern as it indicates the presence of pus, which is often a sign of infection. Purulent drainage can be yellow, green, or brown and is usually thick and malodorous. The presence of pus suggests that there are bacteria or other pathogens in the wound, and immediate medical intervention is necessary to prevent further complications and promote healing.
Choice D reason: Blood-tinged fluid, or serosanguinous drainage, is common in fresh wounds or after debridement. It indicates a mixture of plasma and red blood cells and can be seen in the early stages of wound healing. While it is generally not alarming, the nurse should monitor the volume and changes in the drainage to ensure there are no signs of excessive bleeding or infection.
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