A client who had a C5 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

Reports of chest pain and shortness of breath

Pain and a burning sensation upon urination and hematuria

Profuse diaphoresis and severe, pounding headache

Answer and Explanation

The Correct Answer is D

Choice A reason: Hypotension and venous pooling in the extremities are typically signs of neurogenic shock, which occurs immediately after a spinal cord injury. However, autonomic dysreflexia is characterized by severe hypertension, not hypotension. The symptoms in this scenario do not fit the presentation of autonomic dysreflexia.

Choice B reason: Reports of chest pain and shortness of breath are not the primary symptoms of autonomic dysreflexia. While autonomic dysreflexia can cause a variety of symptoms due to uncontrolled sympathetic nervous system activity, the hallmark symptoms are severe hypertension and headache, along with other specific signs like diaphoresis.

Choice C reason: Pain and a burning sensation upon urination and hematuria indicate a urinary tract infection or another urological issue, not autonomic dysreflexia. While a full bladder is a common trigger for autonomic dysreflexia, the symptoms described in this choice do not accurately reflect the condition.

Choice D reason: Profuse diaphoresis and a severe, pounding headache are classic symptoms of autonomic dysreflexia. This condition results from an overactive autonomic nervous system response to stimuli below the level of the injury, such as a full bladder. The resulting vasoconstriction leads to severe hypertension and symptoms like headache and sweating above the level of injury.

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Correct Answer is D

Explanation

Choice A reason: Comparing the capillary refill in the hands is a useful assessment for evaluating peripheral circulation, but it is not specific to diagnosing carpal tunnel syndrome. Carpal tunnel syndrome involves compression of the median nerve, and capillary refill does not provide information about nerve compression.

Choice B reason: Determining the client's sleeping position may provide insight into factors that exacerbate symptoms, but it does not directly assess for carpal tunnel syndrome. While certain positions might worsen the condition, this information alone is not diagnostic.

Choice C reason: Applying firm pressure over the ulnar artery is not relevant to assessing carpal tunnel syndrome. The ulnar artery supplies blood to the hand, but carpal tunnel syndrome involves the median nerve, not the ulnar artery.

Choice D reason: Tapping the client's wrists to locate the pain, known as Tinel's sign, is a specific test for carpal tunnel syndrome. Tinel's sign is positive when tapping over the median nerve at the wrist elicits tingling or pain in the fingers, indicating nerve compression.

A. Central line insertion. B. Nasogastric tube (NGT) insertion. C. Tracheostomy placement. D. Pacemaker placement.

Correct Answer is C

Explanation

Choice A reason: Central line insertion is not the appropriate intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates airway obstruction, which requires immediate airway management, not central venous access.

Choice B reason: Nasogastric tube (NGT) insertion is not the correct intervention for stridor. NGT insertion is typically used for gastrointestinal decompression or feeding, not for managing airway obstruction.

Choice C reason: Tracheostomy placement is the correct intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates a potential airway obstruction, which can be life-threatening. A tracheostomy provides a secure airway and ensures adequate ventilation.

Choice D reason: Pacemaker placement is not relevant to managing stridor. Pacemakers are used for cardiac rhythm management and do not address airway obstruction.

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A client who had a C5 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 client who works at a computer most of the working day comes to the clinic reporting pain in both hands that causes the client to wake during the night. Which action should the nurse implement to assess for carpal tunnel syndrome?

Correct Answer is D

Explanation

The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure?

Correct Answer is C

Explanation

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