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 ["1.6"]

Explanation

Calculations

Step 1: Identify the prescribed dose.

Prescribed dose = 8 mg

Step 2: Identify the concentration of the vial.

Concentration = 10 mg per 2 mL

Step 3: Calculate the mL per mg.

2 mL ÷ 10 mg = 0.2 mL per 1 mg

Step 4: Calculate the required volume to administer.

8 mg × 0.2 mL/mg = 1.6 mL

Result

The nurse should administer 1.6 mL to the client.

A. Distinguish the difference between herpes varicella and herpes zoster. B. Explain that the risk of developing shingles decreases with age. C. Affirm that a person with shingles has a history of chickenpox infection. D. Ask the client to describe the type of shingles that her brother has. E. Instruct client to report the development of fatigue and low-grade fever.

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

Explanation

Choice A reason: Distinguishing the difference between herpes varicella and herpes zoster is important for client education. Herpes varicella (chickenpox) and herpes zoster (shingles) are caused by the same virus, the varicella-zoster virus (VZV). After a person recovers from chickenpox, the virus remains dormant in the nerve tissues and can reactivate years later as shingles. Educating the client about the relationship between these two conditions helps in understanding the risk and nature of shingles.

Choice B reason: Explaining that the risk of developing shingles decreases with age is incorrect. In fact, the risk of developing shingles increases with age, especially in individuals over 50. The immune system's ability to keep the varicella-zoster virus dormant decreases with age, leading to a higher likelihood of reactivation as shingles. Therefore, this choice is not appropriate for client education.

Choice C reason: Affirming that a person with shingles has a history of chickenpox infection is accurate. Shingles occurs when the dormant varicella-zoster virus reactivates in someone who has previously had chickenpox. This information helps the client understand the connection between past chickenpox infection and the potential for developing shingles.

Choice D reason: Asking the client to describe the type of shingles that her brother has is not relevant to the client's own risk or education about shingles. The focus should be on providing accurate information about shingles and its relation to chickenpox, not on the details of another person's condition.

Choice E reason: Instructing the client to report the development of fatigue and low-grade fever is important because these can be early symptoms of shingles. Early identification and treatment of shingles can help manage symptoms and reduce complications. Educating the client on what to watch for and when to seek medical attention is crucial for effective management.

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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

Correct Answer is ["1.6"]

Explanation

A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.

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

Explanation

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