A nurse is caring for a client who has a spinal cord injury and has developed autonomic dysreflexia. Identify the sequence of steps the nurse should take.
(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Administer an antihypertensive medication intravenously.
Confirm that the client's bladder is empty.
Indicate the risk for autonomic dysreflexia in the client's medical record.
Place the client in an upright sitting position.
The Correct Answer is D,B,A,C
Step D (Place the client in an upright sitting position): Elevating the client's head and upper body to an upright position helps to reduce blood pressure by promoting venous pooling in the lower extremities.
Step B (Confirm that the client's bladder is empty): Autonomic dysreflexia is often triggered by bladder distention or urinary retention. By confirming and addressing urinary issues promptly, the nurse can remove the triggering stimulus.
Step A (Administer an antihypertensive medication intravenously): In severe cases where blood pressure remains dangerously high despite other interventions, such as positioning and addressing bladder issues, antihypertensive medications may be necessary to lower blood pressure quickly and prevent complications.
Step C (Indicate the risk for autonomic dysreflexia in the client's medical record): Documentation of the occurrence of autonomic dysreflexia, its triggers, and interventions used is essential for continuity of care. It informs other healthcare providers about the client's condition and helps in implementing preventive strategies.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A Hydrogen peroxide can be too harsh and irritating to inflamed oral mucosa. It may further aggravate mucositis and delay healing. Therefore, it is not appropriate to recommend rinsing with hydrogen peroxide for a client with mucositis.
B. Brushing for 60 seconds is not enough.
C. Dentures can exacerbate mucositis by causing friction and pressure on the gums and oral mucosa. To reduce irritation, clients should remove dentures when not eating to give their gums and oral tissues a chance to rest and recover.
D. Flossing can help remove food particles and plaque from between the teeth, which could otherwise contribute to infection.
Correct Answer is C
Explanation
C. Cloudy effluent is one of the earliest and most specific signs of peritonitis. It warrants immediate evaluation and diagnostic testing to confirm the diagnosis and initiate appropriate treatment.
A Generalized abdominal pain is a common symptom of peritonitis but may not be the earliest indication.
B. Tachycardia (increased heart rate) can occur in response to infection or inflammation, including peritonitis. It is a systemic response rather than a localized symptom.
D. Fever can also be associated with peritonitis but may appear later and is not as specific early indicators
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