A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client’s current health status is most likely to have precipitated this event?
The client’s urinary catheter became occluded
The client’s analgesia regimen was recently changed
The client was not repositioned during the night shift
The client received a blood transfusion
The Correct Answer is A
Reasoning:
Choice A reason: An occluded urinary catheter is the most likely trigger for autonomic dysreflexia in spinal cord injury above T6. Bladder distension stimulates sympathetic overactivity, causing hypertension and bradycardia. This noxious stimulus below the injury level disrupts autonomic regulation, making catheter occlusion a common precipitant of this condition.
Choice B reason: A changed analgesia regimen is unlikely to cause autonomic dysreflexia. Pain may contribute to discomfort, but dysreflexia typically results from visceral stimuli like bladder or bowel distension. Analgesia changes do not directly trigger the sympathetic overresponse characteristic of this life-threatening condition.
Choice C reason: Failure to reposition may cause pressure injuries but is less likely to precipitate autonomic dysreflexia. While discomfort from immobility can contribute, visceral stimuli like catheter occlusion are more direct triggers, as they strongly activate the sympathetic nervous system below the spinal injury level.
Choice D reason: A blood transfusion is not a common cause of autonomic dysreflexia. Transfusions may cause reactions like fever, but dysreflexia results from stimuli like bladder distension. Transfusion-related complications do not typically trigger the autonomic overresponse seen in spinal cord injury patients with dysreflexia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Reasoning:
Choice A reason: Megaloblastic anemia, caused by vitamin B12 or folate deficiency, impairs DNA synthesis, leading to macrocytic red blood cells. Fatigue results from reduced oxygen-carrying capacity, and a smooth, beefy red tongue (glossitis) is a classic sign due to mucosal cell turnover disruption, matching the client’s symptoms.
Choice B reason: Hemophilia, a bleeding disorder due to clotting factor deficiencies, causes bleeding tendencies like hemarthrosis, not fatigue or glossitis. It does not affect red blood cell production or mucosal tissues, making it inconsistent with the client’s symptoms of anemia and tongue changes.
Choice C reason: Thrombocytopenia, or low platelet count, causes bleeding and bruising, not fatigue or a beefy red tongue. It affects hemostasis, not red blood cell production or mucosal integrity, making it an unlikely cause of the client’s hematologic symptoms described in the scenario.
Choice D reason: Sickle cell disease causes hemolytic anemia and vaso-occlusive pain, not a smooth, beefy red tongue. Fatigue occurs from anemia, but glossitis is specific to megaloblastic anemia due to B12 or folate deficiency, not the hemoglobinopathy of sickle cell disease.
Correct Answer is D
Explanation
Reasoning:
Choice A reason: Infection is not directly related to tissue hypoxia in iron deficiency anemia. Hypoxia results from low hemoglobin, reducing oxygen delivery, but it does not inherently cause infection. Infections may contribute to anemia in chronic disease but are not the primary issue in iron deficiency.
Choice B reason: Deficient fluid volume is not a primary concern in iron deficiency anemia. Impaired erythropoiesis reduces red blood cell production due to low iron, causing anemia, but fluid volume remains normal unless bleeding occurs. Fatigue from low oxygen capacity is more directly linked to the condition.
Choice C reason: Acute pain is not typical in iron deficiency anemia. Pain is associated with hemolytic anemias like sickle cell disease due to vaso-occlusion. Iron deficiency causes fatigue and dyspnea from low hemoglobin, not hemolysis or pain, making this an incorrect association.
Choice D reason: Fatigue related to decreased oxygen-carrying capacity is the most likely issue in iron deficiency anemia. Low iron impairs hemoglobin synthesis, reducing red blood cell oxygen transport, causing tissue hypoxia and fatigue, especially during exertion, directly reflecting the pathophysiology of the client’s condition.
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