A week after a client suffered a high thoracic spinal cord injury in a motor vehicle collision, the blood pressure suddenly rises to 196/126 mm Hg. Which physiological sign(s) should the nurse identify that the client is exhibiting autonomic dysreflexia? select all that apply.
Flushed face.
Urinary urgency.
Pain.
Pale lower extremity.
Bradycardia.
Correct Answer : A,D,E
Rationale:
A. Flushed face: Autonomic dysreflexia causes an exaggerated sympathetic response below the level of injury and a parasympathetic response above it. Vasodilation above the injury leads to facial flushing, nasal congestion, and a warm sensation in the upper body.
B. Urinary urgency: The client typically cannot sense bladder fullness due to spinal cord disruption. Instead, bladder distention acts as the trigger for autonomic dysreflexia, but the client does not perceive urgency because of impaired sensation below the injury level.
C. Pain: Clients with high thoracic or cervical spinal cord injuries do not feel pain below the level of injury. Although pain can sometimes precipitate autonomic dysreflexia, the condition itself does not cause a conscious pain sensation.
D. Pale lower extremity: Vasoconstriction occurs below the level of injury due to excessive sympathetic discharge. This results in cool, pale skin and decreased perfusion in the lower extremities while the upper body shows flushing.
E. Bradycardia: The baroreceptor reflex activates parasympathetic stimulation in response to severe hypertension, resulting in reflex bradycardia. This slowed heart rate is a hallmark feature of autonomic dysreflexia and helps differentiate it from other hypertensive crises.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Use a bed cradle to support linen above the legs: A bed cradle helps prevent pressure from linens on the legs, but it does not address absent or difficult-to-palpate pulses. This intervention is supportive but not diagnostic or priority-focused.
B. Use a Doppler ultrasound to reassess the pulses: When pedal pulses cannot be palpated, a Doppler allows accurate assessment of blood flow and perfusion. Prompt evaluation is essential to detect potential arterial compromise or postoperative complications, such as thrombosis or edema-related vascular obstruction.
C. Elevate the extremities above the level of the heart: Elevation reduces edema but may worsen arterial perfusion if pulses are already absent. Before positioning, confirming circulation with Doppler assessment ensures interventions do not exacerbate ischemia.
D. Wrap the lower extremities with warm blankets: Warming may improve comfort and circulation slightly, but it does not provide objective assessment of vascular status or address potential postoperative vascular compromise.
Correct Answer is C
Explanation
Rationales:
A. Limiting oral fluids can lead to dehydration and concentrated urine, which increases the risk of urinary tract infections and bladder stones in clients with neurogenic bladder following spinal cord injury. Adequate hydration is essential for urinary health.
B. Pelvic floor (Kegel) exercises are effective for clients with intact lower motor neuron function but are ineffective in spinal cord injury because voluntary control over bladder muscles is lost below the level of injury.
C. Intermittent catheterization is the preferred method for managing neurogenic bladder after spinal cord injury. It prevents bladder overdistention, reduces infection risk compared to indwelling catheters, and promotes independence once the client learns self-catheterization.
D. A bedside commode is ineffective for a client with urinary retention due to loss of bladder sensation and voluntary control. The bladder will not empty without catheterization or specific bladder management techniques.
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