A nurse is caring for a client who has an acute spinal cord injury. Which of the following findings should the nurse recognize as autonomic dysreflexia?
Decrease in blood pressure
Increase in heart rate
Client report of eye twitching
Client report of sudden headache
The Correct Answer is D
A. Decrease in blood pressure: Autonomic dysreflexia is characterized by a sudden increase in blood pressure, not a decrease. Hypotension is more typical of spinal shock, making low blood pressure inconsistent with autonomic dysreflexia.
B. Increase in heart rate: During autonomic dysreflexia, the body often responds with bradycardia rather than tachycardia due to baroreceptor-mediated parasympathetic activation. An elevated heart rate is not a typical sign of this condition.
C. Client report of eye twitching: Eye twitching is not associated with autonomic dysreflexia. This symptom may indicate a neurological or electrolyte issue, but it does not help identify the acute hypertensive crisis characteristic of autonomic dysreflexia.
D. Client report of sudden headache: A sudden, severe headache is a hallmark symptom of autonomic dysreflexia caused by abrupt hypertension. This finding, along with other signs such as flushed skin, nasal congestion, and sweating above the level of injury, indicates the need for immediate intervention to prevent complications such as stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Compulsive attention to details: This behavior is more characteristic of obsessive-compulsive personality disorder, not antisocial personality disorder. It reflects a need for order and control rather than disregard for others.
B. Avoids interacting with others: Social withdrawal is typical of avoidant personality disorder. Clients with antisocial personality disorder generally seek interactions they can exploit, rather than avoiding social contact.
C. Uses others for personal gain: Exploiting others for personal benefit is a hallmark of antisocial personality disorder. Clients often display deceitfulness, manipulativeness, and a lack of regard for the rights or feelings of others, consistent with this diagnosis.
D. Socially awkward in group situations: Social awkwardness may be seen in schizoid or schizotypal personality disorders. Clients with antisocial personality disorder usually engage socially in a confident or charming manner when it serves their goals, rather than showing awkwardness.
Correct Answer is D
Explanation
A. Blood pressure 94/68 mm Hg: While slightly on the lower end for a 7-year-old, mild hypotension may not yet be present in severe dehydration because children often maintain blood pressure until significant fluid loss occurs. Blood pressure alone is not the earliest or most sensitive indicator of severe dehydration.
B. Urinary output 30 mL/hr: Normal urinary output for a child is approximately 1 mL/kg/hr. A child with severe dehydration typically has markedly reduced urine output (oliguria), so 30 mL/hr is still be within a low-normal range depending on the child’s weight
C. Respiratory rate 24/mn: This respiratory rate is within normal limits for a 7-year-old (approximately 18–25 breaths/min). It does not reflect compensation for dehydration or hypovolemia and is not a reliable indicator of severe fluid loss.
D. Heart rate 152/min: Tachycardia is an early and sensitive sign of hypovolemia in children. A heart rate of 152/min is significantly elevated for a 7-year-old, indicating compensatory mechanisms to maintain perfusion in response to severe dehydration.
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.