Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?
Administer a prescribed PRN dose of hydralazine.
Assess the client's blood pressures every 15 minutes.
Teach the client to recognize the symptoms of dysreflexia.
Relieve any kinks or obstruction in the client's Foley tubing.
The Correct Answer is D
A) This can be done if initial non-pharmacological interventions do not relieve symptoms, but it is not the first step.
B) Monitoring blood pressure is important, but it is secondary to removing the stimulus causing the dysreflexia.
C) Incorrect- While education is important for long-term management, the client is currently experiencing symptoms that need immediate attention. The priority is to assess and address the current symptoms.
D) The client is likely experiencing autonomic dysreflexia, characterized by a sudden and severe increase in blood pressure, flushing, headache, and other symptoms triggered by a noxious stimulus below the level of injury. The first step in managing autonomic dysreflexia is to identify and eliminate the triggering stimulus. For clients with a Foley catheter, a common cause of autonomic dysreflexia is bladder distention due to a kinked or obstructed catheter. Relieving any kinks or obstructions in the Foley tubing can immediately alleviate the symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","F"]
Explanation
As people age, the turnover of skin cells decreases, resulting in slower wound healing. This can prolong the healing process and increase the risk of complications.
The immune system's function, including T-cell function, tends to decline with age.
T-cells play a crucial role in the immune response and wound healing. Decreased T-cell function can impair the body's ability to fight infection and promote efficient healing.
With aging, there is a natural loss of subcutaneous fat, which can affect wound healing. Subcutaneous fat provides padding and protection to the underlying tissues, and its reduction can increase the risk of tissue damage and delays in healing.
Insulin resistance, pigmentation changes, and polypharmacy are not directly age-related factors that impact wound healing. Insulin resistance is a condition related to impaired glucose metabolism and can affect wound healing in individuals with diabetes or other metabolic disorders, but it is not necessarily an age-related factor. Pigmentation changes and polypharmacy (the use of multiple medications) may be associated with aging but do not directly affect the physiological processes involved in wound healing.
Correct Answer is D
Explanation
The client's statement of feeling worthless most days and having no interest in activities she previously enjoyed indicates a potential risk for self-directed violence, including self-harm or suicidal ideation. These signs are significant and require immediate attention and intervention by the nurse.
Assessing and addressing the client's risk for self-directed violence is of utmost importance to ensure her safety and well-being. The nurse should initiate a thorough assessment of the client's mental health, including assessing for any suicidal ideation, intent, or plans. It is crucial to establish a supportive and non-judgmental environment for the client to express her feelings and concerns.
The nurse should collaborate with the healthcare team to develop an appropriate care plan that may involve interventions such as close observation, involving a mental health professional, implementing safety measures, and providing emotional support.
While addressing other nursing problems, such as anxiety, imbalanced nutrition, and chronic low self-esteem, is important, the immediate concern is the client's risk for self-directed violence due to her feelings of hopelessness.
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