A nurse is assessing an older adult client who has osteoporosis.
Which of the following spinal deformities should the nurse expect to find in this client?

Choice A rationale

While socially appropriate behavior is important, directly confronting a patient with impaired memory due to dementia about their behavior can cause agitation and distress. Their cognitive impairment prevents them from fully understanding and modifying their actions, so this approach is not scientifically effective in this neurological condition. The focus should be on creating a supportive environment.

Choice B rationale

Assisting with all self-care can diminish a patient's autonomy and sense of accomplishment, potentially leading to increased dependence and reduced self-esteem. Promoting independence in activities of daily living, even with supervision or partial assistance, stimulates cognitive function and preserves dignity in individuals with dementia.

Choice C rationale

Maintaining familiar routines provides a structured and predictable environment, which reduces anxiety and confusion in patients with dementia. This consistency helps to preserve residual cognitive function and can improve sleep patterns, appetite, and cooperation with medication administration by minimizing cognitive load and unexpected changes.

Choice D rationale

While orientation is important, repetitive questioning about day, time, and place can be frustrating and upsetting for a patient with severe memory impairment. This approach highlights their deficits and can lead to agitation. Environmental cues and gentle reorientation as needed are more therapeutic than constant questioning.

Choice A rationale

An elevated blood pressure is a symptom of autonomic dysreflexia, not an indication of risk. Autonomic dysreflexia is a medical emergency characterized by an exaggerated sympathetic response below the level of the injury, typically presenting with sudden, severe hypertension (e.g., systolic BP > 20 mmHg above baseline).

Choice B rationale

Nasal congestion is a common symptom of autonomic dysreflexia, caused by peripheral vasodilation above the level of the injury, but it is not the underlying trigger or primary risk factor. It is a consequence of the exaggerated autonomic response.

Choice C rationale

A severe headache is another common symptom of autonomic dysreflexia, resulting from the sudden increase in blood pressure. Like nasal congestion, it indicates the event is occurring, but it is not the direct cause or risk factor for its initiation.

Choice D rationale

Bladder distention is a common noxious stimulus that triggers autonomic dysreflexia in individuals with spinal cord injuries at T6 or above. The distended bladder activates sympathetic reflexes below the injury, leading to widespread vasoconstriction and the rapid onset of severe hypertension.