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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason: Ménière's disease typically presents with vertigo, tinnitus, and hearing loss, not sudden resolution of ear pain with otorrhea.

Choice B reason: Mastoiditis may cause ear pain and drainage, but it is usually accompanied by fever and tenderness over the mastoid bone, not sudden pain resolution.

Choice C reason: A perforated tympanic membrane can lead to the sudden resolution of ear pain followed by drainage, as the pressure causing the pain is relieved when the eardrum ruptures.

Choice D reason: Acoustic neuroma typically presents with progressive hearing loss and tinnitus, not ear pain or otorrhea.

A. Apply heat for 10 minutes every hour. B. Sleep in a side lying position with flexed knees. C. Avoid prolonged sitting. D. Use padded shoe insoles. E. Sleep on a soft matress

Correct Answer is ["A","B","C"]

Explanation

Choice A: Apply heat for 10 minutes every hour
Applying heat can help to relax the muscles and relieve tension, which can reduce pain. Heat therapy increases blood flow, which can aid in healing and reduce stiffness.

Choice B: Sleep in a side lying position with flexed knees
Sleeping in a side-lying position with flexed knees can help to maintain the natural curve of the spine and reduce strain on the back muscles. It's also recommended to use a pillow between the knees for additional support.

Choice C: Avoid prolonged sitting
Prolonged sitting can put pressure on the discs in your lower back and cause or exacerbate pain. It's recommended to take regular breaks to stand up and move around.

Choice D: Use padded shoe insoles
While padded shoe insoles can provide comfort and support for some people, there's no strong evidence to suggest that they can help to prevent or relieve back pain.

Choice E: Sleep on a soft mattress
Contrary to popular belief, a soft mattress may not be the best choice for people with back pain. A mattress that's too soft can cause your back to sink into the mattress, leading to poor sleep posture and discomfort. It's generally recommended to choose a mattress that provides good support and maintains the spine's natural alignment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who reports ear pain for the past three days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions?

Correct Answer is C

Explanation

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Correct Answer is ["A","B","C"]

Explanation

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