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 ["A","C","G"]

Explanation

A. Regular physical activity is a cornerstone of prediabetes management. Exercise helps improve insulin sensitivity, promotes weight loss, and reduces the risk of progression to type 2 diabetes.
C. Weight reduction is an essential component of prediabetes management, especially for individuals who are overweight or obese. Losing as little as 5-10% of body weight can significantly improve insulin sensitivity and reduce the risk of developing type 2 diabetes.
G. Nutrition education: Nutrition education is a crucial component of prediabetes management. Providing education on healthy eating habits, portion control, carbohydrate counting, and making nutritious food choices can empower individuals with prediabetes to make positive dietary changes that support blood sugar control and overall health.
B. Short-acting insulin is not typically used in the treatment of prediabetes. Insulin therapy is usually reserved for individuals with type 1 diabetes or advanced type 2 diabetes who cannot adequately control blood sugar levels with oral medications or lifestyle interventions.
D. While oral antidiabetic medications may be prescribed for individuals with type 2 diabetes, they are not typically used as first-line therapy for prediabetes. Lifestyle modifications, such as diet and exercise, are usually the primary approach for managing prediabetes.
E. Individuals with prediabetes should generally aim to moderate their carbohydrate intake, particularly refined carbohydrates and added sugars, to help improve blood sugar control and reduce the risk of developing type 2 diabetes.
F. Similar to short-acting insulin, long-acting insulin is not typically used in the treatment of prediabetes. Insulin therapy is generally reserved for individuals with type 1 diabetes or advanced type 2 diabetes who require insulin to control blood sugar levels.

A. Teach the client about phantom pain symptoms. B. Perform a complete mental status exam. C. Determine if the client has had a shingles vaccination. D. Complete an assessment of the client's pain.

Correct Answer is D

Explanation

D. Persistent pain following the resolution of herpes zoster, known as postherpetic neuralgia (PHN), is a common complication, especially in older adults. PHN can cause significant discomfort and affect the client's quality of life. Therefore, it is essential for the nurse to conduct a comprehensive assessment of the client's pain to better understand its characteristics, severity, duration, aggravating or alleviating factors, and impact on daily activities.
A. Patient education should follow a complete assessment of the pain to ascertain the diagnosis.
B. Performing a complete mental status exam is not indicated solely based on the client's report of persistent pain from herpes zoster.
C. Determining if the client has had a shingles vaccination is important for preventive healthcare, but it is not the priority action in addressing the client's current pain concern related to PHN. The focus should be on assessing and managing the client's pain to improve their comfort and well-being.

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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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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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