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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Correct choice:right infront of the ear
Rationale
Chvostek's sign is a clinical indicator of hypocalcemia (low calcium levels in the blood). It suggests increased neuromuscular irritability due to low calcium levels affecting nerve excitability.
To elicit Chvostek's sign, the examiner taps lightly over the facial nerve in front of the earlobe. A positive response is observed as twitching or spasm of the facial muscles, typically the lips, nose, and cheek on the same side.
Correct Answer is B
Explanation
B. HbA1c is considered the gold standard for assessing long-term glycemic control in individuals with diabetes. It provides an overall picture of how well blood sugar levels have been controlled over the preceding 2-3 months, helping healthcare providers adjust treatment plans as needed.
A Postprandial (after-meal) blood glucose levels indicate how well blood sugar levels are controlled after eating. While important for immediate assessment of glucose management after meals, it does not provide a comprehensive view of long-term glycemic control.
C. While fasting blood glucose levels are important in daily diabetes management, they do not provide the extended timeframe assessment that HbA1c does for long-term control.
D. OGTT results are not typically used to monitor long-term glycemic control in individuals with established diabetes mellitus. It assesses how the body responds to a glucose load and is not as practical or common for routine monitoring compared to HbA1c.
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