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 ["D","E"]

Explanation

Choice A reason: Bradycardia, or a slower than normal heart rate, is not typically an indication of infection. It can be related to other health issues or medication effects.

Choice B reason: An increase in platelets, or thrombocytosis, can occur in response to various conditions, but it is not a specific indicator of infection in diabetic foot pain.

Choice C reason: An increase in RBCs, or erythrocytosis, is generally not associated with infection. It could indicate other conditions such as polycythemia vera.

Choice D reason: Localized edema, or swelling, can be a sign of infection, especially if accompanied by other symptoms such as redness, warmth, and pain.

Choice E reason: An increase in neutrophils, a type of white blood cell, often indicates the body's response to an infection. Neutrophils are part of the immune system's first line of defense against pathogens.

A. Asthma B. Glaucoma C. Depression D. Migraines

Correct Answer is A

Explanation

Choice A reason: Propranolol is contraindicated in patients with asthma as it may cause bronchoconstriction, exacerbating respiratory difficulties.

Choice B reason: Glaucoma is not a contraindication for propranolol; in fact, betablockers can be used to treat glaucoma by reducing intraocular pressure.

Choice C reason: Depression is not a direct contraindication, but caution is advised as propranolol can sometimes worsen symptoms of depression.

Choice D reason: Propranolol is often used as a preventive treatment for migraines and is not contraindicated in patients with this condition.

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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 has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

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Correct Answer is A

Explanation

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