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 D

Explanation

A. Hypotension is not typically associated with adrenal cortex hyperfunction; in fact, patients may experience hypertension due to excess cortisol and aldosterone.
B. Dehydration is more common with adrenal insufficiency than hyperfunction, as excess hormone production often leads to fluid retention.
C. Hyponatremia is generally not a concern with adrenal cortex hyperfunction; clients may experience hypernatremia instead due to fluid retention.
D. Hypokalemia is a significant risk in clients with adrenal cortex hyperfunction, especially due to the effects of excessive aldosterone, which promotes sodium retention and potassium excretion.

A. Edema of the ear canal. B. Purulent drainage from the ear canal. C. Burning in the ear canal. D. Pain when moving the auricle. E. External ear tender to touch.

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Edema of the ear canal is a common symptom of external otitis, indicating inflammation and infection in the area.
B. Purulent drainage from the ear canal often signifies bacterial infection and is a key symptom to monitor.
C. Burning in the ear canal can occur due to inflammation and is a common complaint in external otitis.
D. Pain when moving the auricle is a classic symptom of external otitis, indicating irritation or inflammation of the external ear.
E. Tenderness of the external ear is a common finding in external otitis and should be monitored as it indicates inflammation and potential infection.

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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

A nurse is caring for a client with Adrenal Cortex Hyperfunction. The nurse is aware that the client is at risk for which of the following?

Correct Answer is D

Explanation

A nurse is caring for a client that has been diagnosed with external otitis. Which of the following clinical symptoms should the nurse be monitoring?

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is performing a tonometry test on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23 mm Hg. What should the nurse's initial action be?

A nurse is assessing a client diagnosed with diabetes insipidus. The nurse should expect which of the following assessment findings?

A nurse is caring for a client newly diagnosed with hyperthyroidism. The nurse recognizes that which of the following is a potential severe complication of hyperthyroidism?

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? Select all that apply.

A client is admitted for treatment of the Syndrome of Inappropriate Antidiuretic Hormone (SIADH). The nurse should initiate which of the following interventions?

A nurse is providing education regarding the adrenal cortex production of mineralocorticoids. The nurse should include that mineralocorticoids influence which of the following?

A nurse is assessing a client with Cushing's syndrome. The nurse is aware that an exogenous cause of Cushing's syndrome is which of the following?

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?