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.
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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Related Questions
Correct Answer is B
Explanation
A. RBC count is typically not elevated in acute pancreatitis.
B. Amylase is an enzyme that increases in the blood during acute pancreatitis due to pancreatic inflammation and enzyme leakage.
C. Magnesium levels are not characteristically elevated.
D. Calcium levels are often decreased in acute pancreatitis due to fat saponification.
Correct Answer is D
Explanation
A. Atelectasis is collapse of lung tissue, not characterized by paradoxical chest movement.
B. Hemothorax is blood in the pleural space, which causes respiratory distress but not paradoxical chest movement.
C. Pneumothorax involves air in the pleural space and can cause respiratory distress, but the hallmark is decreased or absent breath sounds, not paradoxical chest movement.
D. It occurs when multiple adjacent ribs are fractured in multiple places, causing a segment of the chest wall to move paradoxically—inward during inspiration and outward during expiration. This is a life-threatening condition requiring immediate attention.
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