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 D
Explanation
Reasoning:
Choice A reason: Weakness is a general symptom in sickle cell disease due to chronic anemia and reduced oxygen delivery but is not specific to liver complications. Weakness results from systemic hypoxia or energy depletion, not localized hepatic vaso-occlusion or damage, making it less indicative.
Choice B reason: Fatigue is common in sickle cell disease due to chronic hemolysis and anemia but does not specifically indicate liver complications. It reflects reduced red blood cell oxygen-carrying capacity, not hepatic involvement, which requires more localized signs like pain to confirm organ-specific issues.
Choice C reason: Glucose intolerance is not a typical liver complication in sickle cell disease. While chronic disease may affect metabolism, liver complications in SCD involve vaso-occlusion or iron overload, not direct glucose regulation issues, making this finding less relevant to hepatic involvement in this context.
Choice D reason: Abdominal pain, particularly in the right upper quadrant, indicates a liver complication in sickle cell disease. Vaso-occlusion in hepatic vessels or iron overload from transfusions can cause hepatic ischemia or hepatomegaly, leading to pain, a specific sign of liver involvement in SCD exacerbations.
Correct Answer is D
Explanation
Reasoning:
Choice A reason: Continuous oxygen therapy is not a standard preventive measure for sickle cell crises. Oxygen is used during acute crises to treat hypoxia from vaso-occlusion, but daily hydration is more effective for prevention, as it reduces blood viscosity and sickling, making this inappropriate.
Choice B reason: Avoiding all sports is overly restrictive for sickle cell anemia. Moderate exercise can be safe with proper hydration and rest. Complete avoidance does not directly prevent crises and may reduce quality of life, whereas hydration directly addresses the risk of sickling and vaso-occlusion.
Choice C reason: Avoiding activities causing shortness of breath is partially correct, as overexertion can trigger hypoxia and crises. However, it is less specific than hydration, which directly reduces blood viscosity and sickling, preventing crises more effectively across various situations, not just during exertion.
Choice D reason: Drinking at least 8 glasses of water daily is critical in sickle cell anemia to prevent crises. Adequate hydration reduces blood viscosity, preventing red blood cell sickling and vaso-occlusion. Dehydration increases sickling risk, making consistent fluid intake a key preventive strategy for this client.
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