A nurse is caring for a client who has a spinal cord injury and is developing autonomic dysreflexia. Which of the following actions should the nurse take first?
Place the client in a sitting position
Check the client for a fecal impaction
Examine the client for areas of skin breakdown
Check the blood pressure for discrepancies
The Correct Answer is A
Choice A reason: Placing the client in a sitting position helps to lower blood pressure by promoting venous return and is the first action to take in cases of autonomic dysreflexia.
Choice B reason: Checking for a fecal impaction is important as it can be a trigger for autonomic dysreflexia, but it is not the first action to take.
Choice C reason: Examining for areas of skin breakdown is part of ongoing care for clients with spinal cord injuries but is not the immediate priority in autonomic dysreflexia.
Choice D reason: Checking blood pressure is important for monitoring the severity of autonomic dysreflexia, but the first action is to address the positioning of the client to manage the hypertensive crisis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Diabetes mellitus is not directly associated with acute pancreatitis. However, longstanding diabetes can lead to chronic pancreatitis due to the damage it causes to the pancreas over time.
Choice B reason: Hyperlipidemia, specifically high levels of triglycerides in the blood, can be a risk factor for acute pancreatitis. Elevated triglyceride levels above 1000 mg/dL can precipitate an episode of acute pancreatitis.
Choice C reason: Gallstones are a common cause of acute pancreatitis. They can block the bile duct, leading to pancreatitis. It's estimated that gallstone disease is responsible for 3040% of acute pancreatitis cases.
Choice D reason: A criminal record is not a medical condition and has no relevance to the development of acute pancreatitis.
Correct Answer is C
Explanation
Choice A reason: While excessive alcohol consumption is a well known cause of liver cirrhosis, it is not typically associated with biliary cirrhosis1.
Choice B reason: Hepatotoxic medications can lead to liver damage, but they are not the primary cause of biliary cirrhosis1.
Choice C reason: Obstruction of the bile duct is a direct cause of biliary cirrhosis, as it can lead to bile accumulation and liver damage1.
Choice D reason: Hepatitis C can cause liver cirrhosis, but it is not a direct cause of biliary cirrhosis1
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