nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as a trigger that the client is going to experience autonomic dysreflexia symptoms?

The client's blood pressure becomes elevated.

The client states having a severe headache.

The client states having nasal congestion.

The client's bladder becomes distended.

Answer and Explanation

The Correct Answer is D

A. Elevated blood pressure is a sign of autonomic dysreflexia, not the trigger.
B. Severe headache is also a symptom, not the cause.
C. Nasal congestion is another clinical manifestation, not a trigger.
D. A full bladder is a common trigger for autonomic dysreflexia in clients with spinal cord injuries at or above the T6 level. This condition is a medical emergency caused by noxious stimuli below the level of injury.

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Correct Answer is ["225"]

Explanation

4 mL × body weight (kg) × % total body surface area (TBSA) burned = total fluid requirement in the first 24 hours

Half of this volume is given in the first 8 hours post-burn (from the time of injury).

The remaining half is given over the next 16 hours.

Step 1: Convert weight from pounds to kilograms
220 lbs ÷ 2.2 = 100 kg

Step 2: Determine % TBSA burned
anterior trunk burns, which corresponds to 18% TBSA (anterior trunk is about 18%).

Step 3: Calculate total fluid volume for 24 hours
4 mL × 100 kg × 18 = 7200 mL total in 24 hours

Step 4: Calculate remaining fluid to give over the next 16 hours
Half (first 8 hours) = 7200 ÷ 2 = 3600 mL (already given)
Remaining 16 hours = 3600 mL

Step 5: Calculate the hourly rate
3600 mL ÷ 16 hours = 225 mL/hour

A. Decreased level of consciousness B. Anuria to activate RAAS C. Tachycardia to maintain cardiac output D. Hypotension to maintain normal limits

Correct Answer is C

Explanation

A. Decreased level of consciousness usually occurs later as shock progresses.
B. Anuria is a late sign of shock, reflecting kidney failure.
C. Tachycardia is the earliest compensatory response to maintain cardiac output when shock begins.
D. Hypotension is a late sign; blood pressure is often maintained initially by compensatory mechanisms.

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nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as a trigger that the client is going to experience autonomic dysreflexia symptoms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["225"]

Explanation

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that shock is developing and compensation is beginning?

Correct Answer is C

Explanation

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