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: Offering the bedpan every 2 hours is not specifically related to preventing urinary tract infections (UTIs) and may not be necessary unless the client has other needs that require frequent toileting.
Choice B reason: Cleansing the perineum from front to back is a standard practice to prevent the spread of bacteria from the anal area to the urethra, which can reduce the risk of UTIs.
Choice C reason: Encouraging fluid intake is crucial for clients with a spinal cord injury because it helps to flush out the urinary tract, preventing the buildup of bacteria that can cause UTIs.
Choice D reason: An indwelling urinary catheter may be necessary for a client with a T4 spinal cord injury who cannot effectively empty the bladder, but it should be used with caution as it can also increase the risk of UTIs. The decision to use an indwelling catheter should be based on a thorough assessment and consideration of all other options.
Correct Answer is B
Explanation
Choice A reason: The normal range for serum creatinine is indeed 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg/dL for females. Serum creatinine is a waste product from the normal breakdown of muscle tissue. As kidneys become impaired for any reason, the serum creatinine level rises due to poor clearance by the kidneys.
Choice B reason: A GFR below 60 mL/min/1.73 m for three months or more is one of the criteria for the diagnosis of chronic kidney disease. GFR is a measure of how well the kidneys filter blood, and a lower GFR indicates poorer kidney function.
Choice C reason: Blood urea nitrogen (BUN) levels should indeed be between 7 and 20 mg/dL. BUN measures the amount of nitrogen in your blood that comes from the waste product urea. Urea is made when protein is broken down in your body. BUN levels can rise with the level of protein in your diet and your kidney function[^10^].
Choice D reason: An increase in serum potassium can indicate hyperkalemia, which may be a sign of acute kidney injury. Potassium is a critical electrolyte, and its levels are tightly regulated by the kidneys. High levels can lead to dangerous heart rhythms.
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