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: The statement is incorrect because TSH does not attach to a protein in the blood; it stimulates the thyroid gland to produce thyroid hormones.

Choice B reason: This choice is partially correct. TSH does stimulate the thyroid gland, but the main purpose of the test is not to measure the 'feeding' of the gland but to assess its function and how well it's producing thyroid hormones.

Choice C reason: This is the correct statement. TSH levels are measured to determine the thyroid gland's activity, which directly influences the metabolic rate. The normal range for TSH levels in adults is typically 0.4 to 4.0 milliunits per liter (mU/L). However, these values can vary slightly based on the laboratory and the age of the individual.

Choice D reason: While TSH does influence energy levels by regulating thyroid hormone production, this choice does not directly explain the purpose of measuring TSH levels.

A. Headache B. Dyspnea C. Red-brown petechiae D. Altered mental status

Correct Answer is B

Explanation

Choice A reason: Headache can be associated with FES; however, it is not typically considered an early sign. It may occur as a part of the broader spectrum of symptoms.

Choice B reason: Dyspnea, or difficulty breathing, is one of the earliest signs of FES. Patients may experience shortness of breath due to fat globules obstructing pulmonary vessels.

Choice C reason: Red-brown petechiae, which are small, pinpoint hemorrhages, can appear on the skin and are a classic sign of FES, often found in the axillary region or on the chest.

Choice D reason: Altered mental status, including confusion and drowsiness, can occur early in FES due to fat emboli traveling to the cerebral circulation.

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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 talking with a client whose thyroid stimulating hormone (TSH) level will be measured. Which of the following statements by the nurse explains the purpose of this test?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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