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 B
Explanation
A. Monitor the client for hypothermia: Hypothermia is not a typical adverse effect of haloperidol. The medication more commonly causes extrapyramidal symptoms and neuroleptic malignant syndrome, which may include hyperthermia rather than hypothermia.
B. Screen the client for tardive dyskinesia: Tardive dyskinesia is a serious, potentially irreversible extrapyramidal side effect associated with long-term use of antipsychotics such as haloperidol. Routine screening using tools like the Abnormal Involuntary Movement Scale (AIMS) is essential to detect early signs and adjust therapy as needed.
C. Check the client's weekly potassium level: Haloperidol does not typically affect potassium levels. Routine electrolyte monitoring is not indicated unless the client has other conditions or is taking medications that affect potassium.
D. Schedule the client for a 24-hr urine collection: A 24-hour urine collection is unrelated to haloperidol therapy. This test is used to assess kidney function or specific metabolic conditions and is not part of routine care for clients taking antipsychotics.
Correct Answer is C
Explanation
A. Decrease intake of citrus foods and beverages: Citrus foods and beverages do not increase the risk of UTIs and may actually support general health through vitamin C. Restricting them is unnecessary and not part of standard UTI prevention education.
B. Wear nylon underwear: Nylon underwear is less breathable than cotton and can increase moisture, promoting bacterial growth. Clients should be advised to wear cotton underwear to reduce UTI risk.
C. Empty the bladder before and after intercourse: Urinating before and after sexual activity helps flush bacteria from the urethra, reducing the risk of infection. This is an effective and recommended preventive measure for clients with a history of UTIs.
D. Increase the time between voiding: Holding urine for extended periods allows bacteria to multiply in the urinary tract and increases the risk of infection. Clients should be advised to void regularly to prevent UTIs.
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.