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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Dextrose 5% in 0.45% sodium chloride IV. – Incorrect. Dextrose is given later, after blood glucose drops below 250 mg/dL to prevent hypoglycemia.
B. Oral hypoglycemic medications. – Incorrect. DKA requires IV insulin, not oral medications.
C. Glucocorticoid medications. – Incorrect. Glucocorticoids can worsen hyperglycemia by increasing blood sugar.
D. 0.9% sodium chloride IV. – Correct Answer. Fluid resuscitation with normal saline is the first priority to correct hypovolemia caused by osmotic diuresis in DKA.
Correct Answer is C
Explanation
A. Inserting an indwelling urinary catheter – Incorrect. While catheterization may be necessary, it is not the highest priority for an unconscious patient.
B. Putting a nasogastric (NG) tube in place – Incorrect. NG tube placement can be useful for feeding or decompressing the stomach, but airway management takes precedence.
C. Maintaining a patent airway – Correct Answer. Airway patency is the top priority in an unconscious patient to prevent aspiration, hypoxia, or respiratory failure.
D. Administering an enema daily – Incorrect. This is not a priority in unconscious patients.
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