A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

An acutely distended bladder.

Profuse forehead diaphoresis.

Skeletal traction misalignment.

A severe pounding headache.

Answer and Explanation

The Correct Answer is A

A.   One of the most common triggers is a distended bladder. When the bladder becomes full, it sends signals to the spinal cord, but due to the injury, these signals are unable to pass beyond the level of injury. This results in uncontrolled sympathetic activation, leading to symptoms such as hypertension, sweating, and headache.
B.   Forehead diaphoresis, or sweating, is a potential symptom of autonomic dysreflexia. However, it is more of a consequence rather than a precipitating factor. It occurs as a result of sympathetic nervous system activation in response to the triggering stimulus.
C.   Skeletal traction misalignment is not a common precipitating factor for autonomic dysreflexia. Autonomic dysreflexia is typically triggered by stimuli related to visceral or autonomic reflexes, such as bladder distention or bowel impaction, rather than mechanical issues like traction misalignment.
D.   A severe pounding headache can occur as a symptom of autonomic dysreflexia, but it is not the primary precipitating factor. The headache is a result of the sudden increase in blood pressure that occurs during autonomic dysreflexia.

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Correct Answer is B

Explanation

B. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys. Elevated serum creatinine levels may indicate impaired kidney function. Since contrast agents can affect renal function, a serum creatinine level above the reference range should be reported to the healthcare provider before the MRI with contrast.

A. While elevated blood sugar levels may indicate diabetes or poor glycemic control, they are not directly related to kidney function or the risk of contrast-induced nephropathy. Therefore, this value is not the most pertinent for reporting before an MRI with contrast.
C.Glycosylated hemoglobin (HbA1c) reflects average blood glucose levels over the past two to three months and is used to assess long-term glycemic control in diabetes. While elevated HbA1c levels suggest poor diabetes management, they do not directly assess kidney function or the risk of contrast-induced nephropathy.
D. Blood urea nitrogen (BUN) levels reflect the amount of urea nitrogen in the blood and can indicate kidney function. Elevated BUN levels may suggest impaired renal function. However, an elevated serum creatinine is a more reliable marker for renal excretion.

A. Notify the healthcare provider of any change in sputum color. B. Stay in the house if the outdoor temperature is hot and humid. C. Avoid going outdoors whenever the pollen count is high. D. Keep a food diary for one week and bring to next appointment.

Correct Answer is A

Explanation

A. Changes in sputum color can indicate exacerbations of COPD, such as infection or increased inflammation in the airways. Darker or greenish sputum may suggest the presence of infection, while changes in consistency or volume can also indicate worsening respiratory status. Promptly notifying the healthcare provider of any change in sputum color allows for timely assessment and appropriate management.
B. Staying indoors during hot and humid temperature is relevant for minimizing exposure to environmental triggers that can exacerbate COPD symptoms, but it may not be as immediately critical
C. Avoiding allergens is important for clients with asthma who are sensitive to allergens but not COPD
D. Foods taken are more relevant in asthmatic patients as opposed to those with COPD.

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A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

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