A nurse is caring for a patient who has a T-4 spinal cord injury. Which of the following patient findings should the nurse identify as placing the at risk for developing autonomic dysreflexia?
The patient states having nasal congestion.
The patient's blood pressure becomes elevated.
The patient's bladder becomes distended.
The patient states having a severe headache.
The Correct Answer is C
A. The patient states having nasal congestion. – Incorrect. Nasal congestion is a symptom of autonomic dysreflexia, not a trigger.
B. The patient’s blood pressure becomes elevated. – Incorrect. Hypertension is a symptom of autonomic dysreflexia, not the cause.
C. The patient’s bladder becomes distended. – Correct Answer. Bladder distention is the most common trigger of autonomic dysreflexia, a life-threatening condition causing sudden hypertension, bradycardia, and severe headache. Immediate intervention is needed, such as catheterizing the bladder.
D. The patient states having a severe headache. – Incorrect. A severe headache is a symptom of autonomic dysreflexia, not a cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Chart – Contains patient information but is not used for immediate verification before transfusion.
B. Order sheet – Ensures the transfusion is ordered but does not confirm patient identity.
C. Medication administration record – Lists medications but is not used to verify transfusion identity.
D. Identification wristband – Correct Answer. The wristband is the most accurate and immediate source for patient verification before administering blood products.
Correct Answer is A
Explanation
A. Loosen the patient's restrictive clothing – This helps prevent airway obstruction and allows for better chest expansion during the seizure.
B. Open the patient’s jaws to insert an oral airway – Never attempt to force open the mouth during a seizure, as it can cause injury.
C. Restrain the patient to prevent injury – Restraining can cause further harm and should be avoided. Instead, clear the area around the patient to prevent injury.
D. Place patient in high-Fowler’s position – The patient should be placed in a side-lying position to prevent aspiration, not high-Fowler’s.
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