A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?

Third-spacing and hyperthermia

Bradycardia and hypertension

Tachycardia and agitation

Respiratory distress and projectile vomiting

Answer and Explanation

The Correct Answer is B

Reasoning:

Choice A reason: Third-spacing and hyperthermia are not typical of autonomic dysreflexia, a condition in spinal cord injury causing sympathetic overactivity. Third-spacing occurs in fluid shifts like edema, and hyperthermia suggests infection, not the autonomic response to stimuli like bladder distension triggering dysreflexia.

Choice B reason: Autonomic dysreflexia, common in spinal cord injuries above T6, causes bradycardia and hypertension. Noxious stimuli (e.g., bladder distension) trigger sympathetic overactivity, raising blood pressure, while baroreceptors stimulate vagal response, slowing heart rate, making these classic manifestations of this life-threatening condition.

Choice C reason: Tachycardia and agitation may occur in other conditions but are not primary in autonomic dysreflexia. Hypertension triggers a compensatory bradycardia, not tachycardia, and while agitation may accompany distress, the hallmark is the cardiovascular response, making this less accurate.

Choice D reason: Respiratory distress and projectile vomiting are not primary manifestations of autonomic dysreflexia. While severe hypertension may cause nausea, the classic signs are bradycardia and hypertension due to sympathetic overactivity from stimuli below the spinal injury, not respiratory or vomiting issues.

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Correct Answer is D

Explanation

Reasoning:

Choice A reason: Impaired physical mobility is a concern in Addisonian crisis due to weakness from cortisol deficiency, but it is not the highest priority. Acute crisis causes severe hypovolemia and hypotension, which threaten cardiac output and organ perfusion, making mobility a secondary issue compared to life-threatening cardiovascular instability.

Choice B reason: Imbalanced nutrition is relevant in chronic Addison’s disease due to weight loss and poor appetite, but in acute crisis, it is not the priority. Severe hypotension and electrolyte imbalances from adrenal insufficiency pose immediate threats to life, requiring urgent correction before addressing nutritional deficits.

Choice C reason: Risk for infection is a concern in Addison’s disease due to cortisol’s role in immune function, but it is not the primary issue in acute crisis. Hypovolemia, hypotension, and electrolyte imbalances drive life-threatening cardiovascular collapse, making infection risk secondary to stabilizing cardiac output and fluid status.

Choice D reason: Decreased cardiac output is the highest priority in Addisonian crisis, as adrenal insufficiency causes severe hypotension and hypovolemia due to aldosterone and cortisol deficiencies. This leads to reduced cardiac preload and shock, requiring urgent fluid and steroid replacement to restore perfusion and prevent organ failure.

A. Chest radiograph B. ECG C. CBC D. Antibiotic

Correct Answer is C

Explanation

Reasoning:

Choice A reason: A chest radiograph evaluates lung or cardiac issues but is not the first test for symptoms of tiredness, coldness, and shortness of breath with tachycardia. These suggest anemia, and a CBC directly assesses hemoglobin and red blood cell counts, making it more relevant than imaging for initial evaluation.

Choice B reason: An ECG assesses cardiac rhythm and ischemia, useful for tachycardia, but it does not address the underlying cause of fatigue, coldness, and dyspnea. These symptoms suggest anemia, and a CBC is needed to confirm low hemoglobin before evaluating cardiac function with an ECG.

Choice C reason: A complete blood count (CBC) is the most appropriate test, as tiredness, coldness, shortness of breath, and tachycardia suggest anemia. A CBC measures hemoglobin, hematocrit, and red blood cell indices, identifying anemia’s presence and type, guiding further diagnostic and therapeutic interventions for the client’s symptoms.

Choice D reason: Antibiotics treat infections, but tiredness, coldness, dyspnea, and tachycardia point to anemia, not infection. Without fever or infection signs, antibiotics are inappropriate. A CBC is needed to confirm anemia as the cause, making it the priority over empirical antibiotic therapy.

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A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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