A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreflexia. Which of the following actions should the nurse take first?
Raise the head of the bed.
Check the client for a fecal impaction.
Check the client's bladder for distention.
Ensure the room temperature is warm.
The Correct Answer is A
If a nurse is caring for a client who has a spinal cord injury and suspects that the client has autonomic dysreflexia, the first action the nurse should take is to raise the head of the bed. This can help to lower the client's blood pressure and reduce the risk of complications such as stroke.
b. Checking the client for a fecal impaction is an important step in identifying and treating the underlying cause of autonomic dysreflexia, but it is not the first action the nurse should take.
c. Checking the client's bladder for distention is an important step in identifying and treating the underlying cause of autonomic dysreflexia, but it is not the first action the nurse should take.
d. Ensuring that the room temperature is warm is not a priority intervention for a client who has autonomic dysreflexia.
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Correct Answer is B
Explanation
The nurse should place the client's right leg in abduction following a right total hip arthroplasty. Abduction means moving the leg away from the midline of the body. This position helps to prevent hip dislocation by keeping the hip joint in proper alignment.
Internal rotation, adduction, and external rotation are not appropriate positions for the client's right leg following a right total hip arthroplasty. Internal rotation means turning the leg inward towards the midline of the body. Adduction means moving the leg towards the midline of the body. External rotation means turning the leg outward away from the midline of the body. These positions can increase the risk of hip dislocation.
Correct Answer is D
Explanation
The nurse should reinforce to the client that Buck's traction promotes relief from muscle spasms. Buck's traction is a type of skin traction that is widely used for fractures of the femur and hip². It uses splints, bandages, and adhesive tapes to position a limb near the fracture and then applies pressure using weights and pulleys. One of the goals of Buck's traction is to lessen or eliminate muscular spasms.
a. Reduction of the fracture is not the primary purpose of Buck's traction.
b. Support for moving the extremity is not a primary outcome of Buck's traction.
c. Alignment of the pins is not applicable to Buck's traction as it does not involve inserting pins into the
bone.
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