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 D

Explanation

A. Decreasing the client's oral fluid intake is inappropriate in the postoperative period following a TURP, as adequate hydration is essential to prevent clot formation and maintain catheter patency. Limiting fluids could lead to increased clot formation and obstructed flow.
B. Weighing the client every evening is not a relevant intervention in the immediate postoperative period of TURP. Weight monitoring is more critical for fluid balance in chronic conditions such as heart failure or renal disease, not in the acute setting after TURP.
C. Monitoring urine output every 6 hours is insufficient for a client receiving continuous bladder irrigation. Immediate postoperative care requires more frequent monitoring to detect potential complications such as clot retention or hemorrhage.
D. Reminding the client that he might feel a constant urge to void is essential. Continuous bladder irrigation can cause bladder spasms and a persistent sensation of needing to urinate, which is common after TURP. This helps the client understand and cope with these sensations, reducing anxiety and unnecessary concern.

A. Assess for sources of bleeding and provide pressure on wounds B. Limit contact with infected visitors and place in positive pressure isolation C. Administer antiemetics and assess nutrition and hydration status D. Monitor energy levels and begin energy-conserving techniques

Correct Answer is B

Explanation

A. Assessing for sources of bleeding is important in clients with neutropenia, but the highest priority is preventing infection, as the client’s absolute neutrophil count is zero, indicating an extremely high risk for infection.
B. Limiting contact with infected visitors and placing the client in positive pressure isolation is crucial for preventing infections. With a neutrophil count of zero, the client is highly immunocompromised and at a significant risk of infection, making this the highest priority action.
C. Administering antiemetics and assessing nutrition and hydration are important for managing symptoms, but they do not address the immediate risk of infection associated with severe neutropenia.
D. Monitoring energy levels and implementing energy-conserving techniques are important for overall care but do not address the urgent need to protect the client from infections due to their neutropenic status.

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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?

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