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.

Answer and Explanation

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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Correct Answer is A

Explanation

A Canola oil is a healthier choice compared to saturated fats like butter or coconut oil because it is lower in saturated fat and high in unsaturated fats (monounsaturated and polyunsaturated fats). Using canola oil can help lower LDL (bad) cholesterol levels and reduce the risk of heart disease.

B. Canned vegetables often contain added sodium as a preservative, which can contribute to hypertension (high blood pressure), a risk factor for cardiovascular disease. Therefore, increasing intake

of canned vegetables is not recommended for someone with cardiovascular disease unless they are choosing low-sodium or no-added-salt varieties.

C. Limiting portions of meat helps reduce intake of saturated fats, which can raise LDL cholesterol levels and increase the risk of heart disease. A portion size of 8 ounces is appropriate as part of a heart-healthy diet that emphasizes lean proteins and plant-based sources of protein.

D. Whole milk is higher in saturated fat compared to low-fat or skim milk. Consuming saturated fats increases LDL cholesterol levels, which can contribute to cardiovascular disease. Therefore, drinking whole milk is not recommended for someone with cardiovascular disease who should focus on reducing saturated fat intake.

A. Kussmaul respirations B. Increased urine output C. Cool, clammy skin D. Acetone breath

Correct Answer is C

Explanation

C. Cool, clammy skin is a common symptom of hypoglycemia. When blood sugar levels drop too low, the body's sympathetic nervous system is activated, causing sweating and cool, clammy skin as a response to the stress of low blood sugar.

A Kussmaul respirations are deep, rapid, and labored breathing patterns that occur in response to diabetic ketoacidosis (DKA), a complication of hyperglycemia rather than hypoglycemia. In hypoglycemia, the body typically responds with normal or shallow respirations.

B Increased urine output (polyuria) is more commonly associated with hyperglycemia, where the kidneys try to excrete excess glucose through urine. Hypoglycemia typically does not cause increased urine output.

D. Acetone breath, which has a fruity odor, is associated with diabetic ketoacidosis (DKA), a condition caused by severe hyperglycemia and metabolic acidosis. It is not a typical finding in hypoglycemia.

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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.)

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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.)