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 C
Explanation
Choice A rationale
Bell's Palsy causes unilateral facial muscle weakness or paralysis, leading to difficulty closing the eye and impaired tear production on the affected side. A fan could further dry the compromised eye, potentially causing irritation and corneal damage.
Choice B rationale
Bell's Palsy primarily affects facial nerve (Cranial Nerve VII) function, which controls facial expressions, taste, and lacrimation. While some patients may experience mild dysphagia, aspiration precautions are not typically the primary or most common concern, as the vagus nerve (Cranial Nerve X) controls swallowing.
Choice C rationale
Due to paralysis of the orbicularis oculi muscle, patients with Bell's Palsy cannot adequately close their affected eye. This can lead to corneal dryness, irritation, and potential ulceration. Therefore, protecting the eye with artificial tears, eye patches, or ointments is crucial to prevent corneal damage.
Choice D rationale
Bell's Palsy is characterized by sudden facial paralysis and may cause discomfort or pain in some individuals, but it is not typically known for severe, debilitating pain requiring primary focus on pain relief. The primary interventions revolve around eye protection and managing the facial paralysis.
Correct Answer is D
Explanation
Choice A rationale
A ventricular pacemaker is designed to pace the ventricles, not the atria. Therefore, a pacemaker spike appearing before each P wave would indicate atrial pacing, which is not the primary function of a ventricular pacemaker. P waves represent atrial depolarization, and a ventricular pacemaker's stimulus is delivered to the ventricles to initiate a QRS complex.
Choice B rationale
A pacemaker spike appearing after each QRS complex suggests either oversensing, undersensing with competitive rhythms, or a malfunction. The purpose of a pacemaker spike is to *initiate* depolarization, not to follow it. If the spike occurs after the QRS, it indicates that the ventricle has already depolarized, and the spike is not contributing to ventricular contraction.
Choice C rationale
A pacemaker spike appearing with each T wave would be inappropriate and potentially dangerous. The T wave represents ventricular repolarization, a vulnerable period during which an electrical stimulus can induce life-threatening arrhythmias like ventricular fibrillation (R-on-T phenomenon). Pacing should occur before ventricular depolarization, not during repolarization.
Choice D rationale
A ventricular pacemaker functions by delivering an electrical impulse to the ventricle when its intrinsic rate falls below a programmed threshold. This impulse, seen as a pacemaker spike on the ECG, should precede ventricular depolarization, thus initiating a QRS complex. This indicates that the pacemaker is effectively stimulating ventricular contraction at the appropriate time.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.