A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

Hypotension and venous pooling in the extremities.

Pain and a burning sensation upon urination and hematuria.

Profuse diaphoresis and severe, pounding headache.

Reports of chest pain and shortness of breath.

Answer and Explanation

The Correct Answer is C

Choice A reason: Hypotension and venous pooling in the extremities are not typical of autonomic dysreflexia. Autonomic dysreflexia usually results in hypertension due to an exaggerated autonomic response to a stimulus such as a full bladder. This condition is characterized by severe, uncontrolled hypertension rather than hypotension.

Choice B reason: While pain and a burning sensation upon urination and hematuria can be related to a urinary tract infection or bladder issue, they are not specific to autonomic dysreflexia. Autonomic dysreflexia presents with symptoms that result from the body's exaggerated response to the stimulus, such as severe headache and sweating.

Choice C reason: The correct answer is c) because profuse diaphoresis (sweating) and a severe, pounding headache are hallmark signs of autonomic dysreflexia. This condition occurs in individuals with spinal cord injuries at or above the T6 level and is triggered by stimuli like a full bladder, causing a dangerous rise in blood pressure and severe autonomic responses.

Choice D reason: Reports of chest pain and shortness of breath are not typical signs of autonomic dysreflexia. While these symptoms may be concerning, they are not the primary indicators of this specific condition. The severe headache and sweating are more indicative of autonomic dysreflexia.

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Free Nursing Study Resources

Correct Answer is ["0.8"]

Explanation

Calculation steps:

Step 1: Identify the dosage required. 4 mg

Step 2: Identify the concentration available. 5 mg/mL

Step 3: Calculate the volume to be administered. 4 mg ÷ 5 mg/mL Result: 0.8 mL

A. "You have the right to refuse prescribed treatment." B. "You have the right to mail out letters." C. "You have the right to file grievances against staff." D. "You have the right to a private room." E. "You have the right to conduct religious practices."

Correct Answer is ["B","C","E"]

Explanation

Choice A reason: Clients on an involuntary hold may not have the right to refuse treatment if it is deemed necessary for their safety.

Choice B reason: The correct answer is b) because clients have the right to communicate with others, including mailing letters.

Choice C reason: The correct answer is c) because clients have the right to file grievances against staff if they feel their rights are being violated.

Choice D reason: A private room is not a guaranteed right for clients on an involuntary hold.

Choice E reason: The correct answer is e) because clients have the right to practice their religion and conduct religious practices.

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A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer diazepam 4 mg IV bolus stat. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth.)

Correct Answer is ["0.8"]

Explanation

A client newly placed on an involuntary hold is being given an orientation to the psychiatric unit. The nurse includes information about the client's rights. Which of the following statements should the nurse include? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

A nurse is preparing to administer 1500 mL of IV fluid to infuse over 2 hours. The nurse should set the IV pump to deliver how many mL/h?

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A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

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