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 B

Explanation

Reasoning:

Choice A reason: Aspiration precautions are important in head injury to prevent pneumonia, particularly if consciousness is impaired, but they are not specific seizure prophylactic measures. Seizures require anticonvulsants to prevent neuronal hyperexcitability, making aspiration precautions a secondary concern unrelated to seizure prevention.

Choice B reason: Anticonvulsant medications, initiated early (e.g., day two), are standard for seizure prophylaxis in head injury. Trauma can cause cortical irritation, increasing seizure risk. Drugs like levetiracetam stabilize neuronal activity, preventing seizures, which could worsen brain injury or ICP, making this the primary measure.

Choice C reason: Intubation and ventilator support are used for severe head injuries with compromised airway or breathing but are not seizure prophylaxis. Seizures are managed with anticonvulsants, as mechanical ventilation does not address neuronal excitability, making this inappropriate for seizure prevention.

Choice D reason: Antiemetic medications manage nausea but are not seizure prophylactic measures. While vomiting may occur post-head injury, it does not prevent seizures, which result from cortical irritability. Anticonvulsants directly target seizure risk, making antiemetics irrelevant to this specific intervention goal.

A. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks B. The client should mobilize as soon as physically able C. The client should remain on bed rest until the client expresses a desire to mobilize D. Lack of mobility will greatly increase the client’s risk of stroke recurrence

Correct Answer is B

Explanation

Reasoning:

Choice A reason: Limiting bed rest to 4 weeks to prevent contractures and atrophy is not the primary principle. While prolonged immobility causes these issues, early mobilization post-stroke improves recovery and prevents complications like thromboembolism, making immediate mobilization the key focus rather than a time limit.

Choice B reason: Mobilizing as soon as physically able is critical post-ischemic stroke to enhance recovery. Early mobilization improves circulation, prevents thromboembolism, maintains muscle strength, and promotes neuroplasticity, reducing disability. This principle counters the family’s insistence on bed rest, which increases complication risks and hinders recovery.

Choice C reason: Waiting for the client to express a desire to mobilize delays recovery. Stroke patients may lack initiative due to neurological deficits or depression. Early mobilization, guided by physical ability, prevents complications like deep vein thrombosis and supports rehabilitation, making patient desire a poor criterion.

Choice D reason: Lack of mobility does not directly increase stroke recurrence risk, which is more tied to vascular risk factors like hypertension or diabetes. However, immobility increases complications like thromboembolism, which could indirectly contribute to stroke. Early mobilization is the priority to enhance overall recovery.

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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

A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client?

Correct Answer is B

Explanation

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client’s family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse’s response to the family?

Correct Answer is B

Explanation

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