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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A rosebud like stoma orifice is a normal appearance for a new colostomy, indicating that the stoma is healthy and not in distress.
Choice B reason: Red drainage from a stoma can be normal, especially in the early postoperative period, as the stoma may ooze a small amount of blood. However, if the drainage is excessive or persistent, it should be reported.
Choice C reason: A shiny, moist stoma is also a sign of a healthy stoma. The stoma should be moist and have a pink or red color, similar to the inside of the mouth.
Choice D reason: A purplish colored stoma indicates compromised blood flow and is a sign of ischemia. This is a serious complication that requires immediate medical attention to prevent tissue death.
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect. Partial compensation would typically involve a change in PaCO2 to counterbalance the elevated bicarbonate, which is not observed here.
Choice B reason: This choice is incorrect. Respiratory acidosis is characterized by a low pH and an elevated PaCO2, which is not consistent with the given values.
Choice C reason: This choice is incorrect. Respiratory alkalosis would present with a low PaCO2 due to hyperventilation, which is not the case here.
Choice D reason: This is the correct choice. The elevated pH and HCO3 with a normal PaCO2 indicate metabolic alkalosis without respiratory compensation. Persistent vomiting can lead to loss of stomach acid, which causes metabolic alkalosis.
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