A nurse is caring for a client with suspected pheochromocytoma. The nurse recognizes that which of the following is the priority action?

Obtain hourly glucose levels

Prepare client for a CT scan

Request order for serum calcium levels

Monitor Blood Pressure

Answer and Explanation

The Correct Answer is D

A. Monitoring glucose levels may be necessary, as pheochromocytoma can cause hyperglycemia, but it is not the immediate priority.
B. A CT scan may be part of the diagnostic process to locate the adrenal tumor, but the priority is to control blood pressure first due to the risk of severe hypertensive crisis.
C. Serum calcium levels are not directly related to pheochromocytoma and are not a priority action.
D. Monitoring blood pressure is critical, as pheochromocytoma causes episodes of severe hypertension, which can lead to life-threatening complications.

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

Explanation

A. Hypertension can occur due to autonomic dysreflexia, especially in clients with cervical spinal cord injuries, as they may have exaggerated sympathetic responses.
B. A weakened gag reflex can result from cranial nerve involvement due to the cervical spinal cord injury, impacting the client's ability to protect their airway.
C. Absence of bowel sounds may indicate bowel immobility or dysfunction; however, it is not a direct complication of a cervical spinal cord injury.
D. Bradycardia is a common finding in cervical spinal cord injuries due to impaired sympathetic nervous system function, leading to decreased heart rate.
E. Tachycardia is less common in cervical injuries and is typically associated with lower injuries in the spinal cord.

A. Lower the client's legs. B. Check for a full bladder. C. Administer a nitrate antihypertensive. D. Administer pain medication.

Correct Answer is B

Explanation

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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A nurse is caring for a client with suspected pheochromocytoma. The nurse recognizes that which of the following is the priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.

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

Explanation

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?

Correct Answer is B

Explanation

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