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. Low levels of PTH would primarily affect calcium metabolism and would not directly explain short stature or delayed menarche.
B. Impaired production of GH is most likely the cause of short stature, as growth hormone plays a critical role in growth and development during childhood.
C. Lack of ACTH affects adrenal hormone production but does not directly lead to short stature or delayed menarche.
D. Impaired production of T3 and T4 would affect metabolism and growth but is less likely to be the primary cause of the symptoms presented compared to growth hormone deficiencies.

A. Note the time of day the test was done. B. Apply normal saline drops. C. Instruct the client to sleep with the head of the bed flat. D. Contact the primary health care provider.

Correct Answer is D

Explanation

A. While noting the time of day is important for documentation, it does not address the immediate concern of elevated intraocular pressure (IOP).
B. Applying normal saline drops is not indicated in the immediate management of elevated IOP in glaucoma; it does not directly affect IOP levels.
C. Instructing the client to sleep with the head of the bed flat is not advisable, as elevated head positions may help decrease IOP.
D. An IOP of 23 mm Hg is above the normal range (10-21 mm Hg) and indicates potential glaucoma. Therefore, contacting the primary health care provider for further evaluation and treatment is the most appropriate initial action.

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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 who had a brain tumor and chemotherapy as an infant. The assessment reveals short stature and delayed onset of menarche. The nurse recognizes the assessed problems are most likely caused by which of the following?

Correct Answer is B

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?

Correct Answer is D

Explanation

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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?