A nurse is caring for a client who has a spinal cord injury at the first thoracic level. Which of the following should the nurse recognize can trigger autonomic dysreflexia?
(Select All that Apply.)
Sexual intercourse
Tight clothing
Nausea
Surgery below level of injury
Urinary tract infections
Correct Answer : A,B,D,E
Choice A Reason:
Sexual intercourse is correct. Stimulation of the genitalia or other areas below the level of injury can trigger autonomic dysreflexia in individuals with spinal cord injuries.
Choice B Reason:
Tight clothing is correct. Any form of tight or restrictive clothing, including belts or waistbands, can stimulate the body below the level of injury and trigger autonomic dysreflexia.
Choice C Reason:
Nausea is incorrect. While nausea itself is not a common trigger for autonomic dysreflexia, it may occur as a result of the condition. Autonomic dysreflexia can cause a variety of symptoms, including nausea, due to the sudden increase in blood pressure.
Choice D Reason:
Surgery below the level of injury is correct. Surgical procedures performed below the level of the spinal cord injury can lead to stimulation of the body below the injury site, triggering autonomic dysreflexia.
Choice E Reason:
Urinary tract infections (UTIs) is correct. Infections of the urinary tract, especially those involving the bladder or urethra, can stimulate the body below the level of injury, leading to autonomic dysreflexia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A Reason:
Spinal cord injuries can disrupt the autonomic nervous system, impairing the body's ability to regulate temperature (thermoregulation). This can lead to temperature sensitivity, with clients experiencing issues such as difficulty sweating, shivering, or adapting to extreme temperatures.
Choice B Reason:
Contractures, which are the shortening and tightening of muscles, tendons, or ligaments, can occur as a complication of spinal cord injuries. Immobility and spasticity commonly seen in SCI can contribute to the development of contractures.
Choice C Reason:
Sexual dysfunction is a common complication of spinal cord injuries. SCI can affect sexual function and reproductive health due to changes in sensation, mobility, and autonomic nervous system function.
Choice D Reason:
Disc degeneration, or degenerative disc disease, typically occurs as a result of aging and wear and tear on the spinal discs. While SCI may lead to changes in spinal alignment and biomechanics, it is not a direct cause of disc degeneration.
Choice E Reason:
Urinary tract infections (UTIs) are a common complication of spinal cord injuries. Neurogenic bladder dysfunction, which is common in SCI, can lead to urinary retention, incomplete bladder emptying, and urinary stasis, increasing the risk of UTIs.
Correct Answer is C
Explanation
A.Osmotic edema refers to fluid shifts due to changes in osmotic gradients (as seen in conditions like hyponatremia), not the inflammatory process of meningitis.
B.While inflammation is a key part of the body's response in meningitis, the edema is not a result of generalized whole-body inflammation. The edema is more directly linked to local inflammatory reactions in the brain triggered by the pathogen’s by-products.
C.Bacterial cell walls, endotoxins, and other components released by the bacteria directly stimulate inflammation, causing the breakdown of the BBB and allowing fluid and inflammatory cells to leak into the brain tissue.
D.This description is more aligned with the pathophysiology of conditions like hydrocephalus rather than meningitis. In meningitis, cerebral edema is primarily due to the inflammatory response, not abnormal CSF flow.
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