A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting?

"My wife tries to get me to go to the grocery store, but I don't like to go out much."

"I have all the equipment to take a shower, but I prefer a bed bath, because it is easier."

"My greatest pleasure each day is having a few beers every day."

"I am using the modified feeding utensils at every meal. I still spill, but I'm

Answer and Explanation

The Correct Answer is D

Choice A Rationale: Expressing a reluctance to go out and preferring to stay indoors is not necessarily indicative of effective adaptation.

Choice B Rationale: Preferring a bed bath may be a personal choice rather than a sign of adaptation.

Choice C Rationale: Consuming alcohol daily as a means of pleasure may not necessarily indicate effective adaptation and may raise concerns about potential dependence.

Choice D Rationale: Using modified feeding utensils at every meal and acknowledging improvement despite occasional spills indicates a positive attitude toward adaptation and learning to manage daily activities despite physical limitations.

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Correct Answer is A

Explanation

Choice A Rationale: Assessing the client for bladder distention is the first and most crucial step in managing autonomic dysreflexia. Bladder distention is a common trigger for this condition in clients with spinal cord injuries. Identifying and addressing the cause (bladder distention) is the priority to prevent further complications.

Choice B Rationale: Laying the client flat may not resolve the underlying cause of autonomic dysreflexia and should be done after identifying and addressing the trigger.

Choice C Rationale: Obtaining the client's heart rate is important but should come after assessing for bladder distention since the primary concern in autonomic dysreflexia is elevated blood pressure due to a noxious stimulus.

Choice D Rationale: Administering a nitrate antihypertensive may be necessary if other interventions do not resolve the blood pressure elevation, but it should not be the first action. Identifying and addressing the cause, such as bladder distention, is the priority.

A. A Sit the client at a 90 degree angle B. B Administer 2000 liters of fluid C. C Apply compression socks D. D Maintain blood pressure exactly at 110/80

Correct Answer is A

Explanation

Choice A Rationale: Sitting the client at a 90-degree angle (upright position) helps prevent orthostatic hypotension and cardiovascular complications in clients with spinal cord injuries by improving venous return and cardiac output.

Choice B Rationale: Administering 2000 liters of fluid is an inappropriate intervention, and the volume mentioned is excessive.

Choice C Rationale: Applying compression socks may help prevent deep vein thrombosis (DVT) but does not address cardiovascular complications related to sitting position.

Choice D Rationale: Maintaining blood pressure exactly at 110/80 is not a feasible or appropriate intervention.

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A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

After performing an assessment on a client with a spinal cord injury, which intervention will the nurse employ to prevent cardiovascular complications?

Correct Answer is A

Explanation

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