A nurse is caring for a client who has a T-4 spinal cord injury.
Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?
The client's blood pressure becomes elevated.
The client states having nasal congestion.
The client states having a severe headache.
The client's bladder becomes distended.
The Correct Answer is D
Choice A rationale
An elevated blood pressure is a symptom of autonomic dysreflexia, not an indication of risk. Autonomic dysreflexia is a medical emergency characterized by an exaggerated sympathetic response below the level of the injury, typically presenting with sudden, severe hypertension (e.g., systolic BP > 20 mmHg above baseline).
Choice B rationale
Nasal congestion is a common symptom of autonomic dysreflexia, caused by peripheral vasodilation above the level of the injury, but it is not the underlying trigger or primary risk factor. It is a consequence of the exaggerated autonomic response.
Choice C rationale
A severe headache is another common symptom of autonomic dysreflexia, resulting from the sudden increase in blood pressure. Like nasal congestion, it indicates the event is occurring, but it is not the direct cause or risk factor for its initiation.
Choice D rationale
Bladder distention is a common noxious stimulus that triggers autonomic dysreflexia in individuals with spinal cord injuries at T6 or above. The distended bladder activates sympathetic reflexes below the injury, leading to widespread vasoconstriction and the rapid onset of severe hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
Step 1: Calculate mL per minute. 100 mL ÷ 60 min = 1.666. mL/min.
Step 2: Multiply mL per minute by the drop factor. 1.666. mL/min × 60 gtt/mL = 100 gtt/min. The nurse should set the IV flow rate to deliver 100 gtt/min.
Correct Answer is B
Explanation
Choice A rationale
Methotrexate does not have a significant interaction with vitamin K. Methotrexate's primary mechanism of action involves inhibiting dihydrofolate reductase, thereby interfering with folate metabolism and DNA synthesis. Vitamin K is crucial for blood clotting factors. There is no contraindication for vitamin K rich foods.
Choice B rationale
Methotrexate excretion is primarily renal, and adequate hydration is critical to prevent nephrotoxicity and facilitate drug elimination. Drinking at least 2 liters of water daily helps maintain good kidney function, ensuring that methotrexate and its metabolites are efficiently cleared from the body, thus minimizing the risk of drug accumulation and associated toxicities.
Choice C rationale
Methotrexate for rheumatoid arthritis is typically administered once weekly, not daily, to mitigate severe adverse effects such as bone marrow suppression, hepatotoxicity, and gastrointestinal complications. Daily dosing would lead to rapid accumulation and dangerously high systemic concentrations, overwhelming the body's detoxification pathways.
Choice D rationale
Alcohol-based mouthwashes should be avoided when taking methotrexate because alcohol can cause mucosal irritation and increase the risk of oral mucositis, a common side effect of methotrexate. Additionally, alcohol can exacerbate hepatotoxicity, a significant concern with methotrexate therapy, by increasing metabolic burden on the liver.
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