A nurse is caring for a client who has quadriplegia due to a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. What should the nurse prioritize as the initial action?

Lower the client's legs.

Check for a full bladder.

Administer a nitrate antihypertensive.

Administer pain medication.

Answer and Explanation

The Correct Answer is B

A. Lowering the client's legs is not effective in managing autonomic dysreflexia and may not alleviate the cause of the high blood pressure.
B. Checking for a full bladder is the priority because bladder distension is a common trigger for autonomic dysreflexia in clients with spinal cord injuries, and relieving it can reduce the severe hypertensive response.
C. Antihypertensives may be used if non-pharmacological measures fail, but addressing the cause is the first action.
D. Pain medication is not indicated as the immediate intervention for autonomic dysreflexia, as the priority is identifying and removing the trigger.

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Correct Answer is A

Explanation

A. Mastoiditis often results in inflammation and infection that extend to the middle ear, causing the tympanic membrane to appear red, dull, thickened, and immobile upon examination.
B. A transparent and clear tympanic membrane is typical in a healthy ear, not in cases of mastoiditis.
C. A pearly colored tympanic membrane is also indicative of a normal, healthy ear without infection.
D. A pink-colored tympanic membrane may suggest mild irritation but is not a characteristic finding of mastoiditis.

A. Place the client in a supine position. B. Instruct client to pull self up in bed C. Use log rolling to reposition the client. D. Assist client to sit with legs dangling

Correct Answer is C

Explanation

A. The supine position can increase ICP and is not recommended for clients with elevated ICP.
B. Instructing the client to pull themselves up may increase ICP due to straining.
C. Log rolling helps maintain spinal alignment and minimizes abrupt head movement, which is essential in managing ICP.
D. Sitting with legs dangling may cause a sudden shift in intracranial pressure and is not advised for these clients.

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A nurse is caring for a client who has quadriplegia due to a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. What should the nurse prioritize as the initial action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?

Correct Answer is A

Explanation

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following positioning techniques should the nurse implement?

Correct Answer is C

Explanation

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A nurse is assessing a client with autonomic dysreflexia. The nurse correlates which clinical manifestations to autonomic dysreflexia in a client with a spinal cord injury?

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