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 B

Explanation

A. Serum thyroxine (T4) is typically decreased in primary hypothyroidism due to reduced thyroid hormone production.
B. In primary hypothyroidism, the thyroid gland fails to produce sufficient hormones, which leads to an increase in thyroid-stimulating hormone (TSH) as the pituitary gland tries to stimulate thyroid function. Elevated TSH is a common finding in primary hypothyroidism.
C. Serum T3 is usually decreased in primary hypothyroidism since the production of T3 and T4 is reduced.
D. Free T4 is typically low in primary hypothyroidism as the thyroid gland is underactive and not producing adequate levels of thyroid hormones.

A. Hypocalcemia B. Hypercalcemia C. Hypokalemia D. Hyponatremia

Correct Answer is A

Explanation

A. Chvostek's sign, a facial muscle spasm upon tapping, is a clinical indicator of hypocalcemia, often caused by accidental removal or damage to the parathyroid glands during thyroid surgery.
B. Hypercalcemia does not typically cause a positive Chvostek’s sign.
C. Hypokalemia affects muscle and cardiac function but does not result in a positive Chvostek’s sign.
D. Hyponatremia does not produce Chvostek's sign, which is specific to hypocalcemia.

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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 in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?

Correct Answer is B

Explanation

A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse assesses for the presence of Chvostek's sign to indicate which of the following electrolyte imbalances?

Correct Answer is A

Explanation

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