A nurse is caring for a client who has a T4 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 states feeling hot and sweaty.

The client's bladder becomes distended.

The client's blood pressure becomes elevated.

The client reports having a severe headache.

Answer and Explanation

The Correct Answer is B

A. Feeling hot and sweaty can occur during autonomic dysreflexia, but it is a symptom of the condition rather than a cause or risk factor.
B. Bladder distension is a common trigger for autonomic dysreflexia, a condition that occurs in individuals with spinal cord injuries at or above the T6 level, due to the excessive autonomic response to noxious stimuli such as a full bladder.
C. Elevated blood pressure is a sign of autonomic dysreflexia, but the risk factor to recognize is the underlying cause, such as bladder distension.
D. A severe headache is a symptom of autonomic dysreflexia, indicating the need for immediate action, but it is not a risk factor for developing the condition.

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Correct Answer is B

Explanation

A. Drying the sclera with a cotton swab prior to administering eye drops is not recommended and could introduce fibers or cause irritation. Proper eye drop administration does not require drying the sclera.
B. Administering the medications 5 minutes apart is correct because it allows each medication to be absorbed properly, preventing the second drop from washing out the first. This timing helps ensure that both medications are effective.
C. Touching the tip of the dropper to the sclera is incorrect and can introduce contaminants, leading to infection. Eye drops should be administered without the dropper touching the eye to maintain sterility.
D. Holding pressure on the conjunctival sac for 2 minutes is excessive. The recommended practice is to gently press on the nasolacrimal duct for 1-2 minutes after administration to prevent systemic absorption, especially with medications like timolol.

A. A change in the Glasgow Coma Scale score from 13 to 10 B. Diplopia C. Ataxia D. A drop in heart rate from 76 to 70/min

Correct Answer is A

Explanation

A. A decrease in the Glasgow Coma Scale score from 13 to 10 indicates a significant change in consciousness and may suggest worsening of the brain injury. This is a critical sign that requires immediate reporting and evaluation.
B. Diplopia (double vision) can be a concerning symptom, but it is not as immediately critical as a significant change in the Glasgow Coma Scale score. It still warrants attention but may not be the highest priority.
C. Ataxia (lack of voluntary coordination of muscle movements) is a serious symptom that could indicate worsening of the brain injury but is not as immediately critical as a significant change in the Glasgow Coma Scale score.
D. A drop in heart rate from 76 to 70/min is generally not significant in the context of mild TBI. Changes in heart rate are less critical compared to changes in the level of consciousness.

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A nurse is caring for a client who has a T4 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?

Nursing Test Bank

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