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 D

Explanation

A. Vitamin K is used to treat coagulopathy in liver disease but does not decrease ammonia levels.
B. Limiting fluid intake is typically related to managing ascites or edema, not ammonia levels.
C. Diuretics help reduce fluid overload but do not directly reduce ammonia.
D. Lactulose promotes the excretion of ammonia through the gastrointestinal tract by acidifying the colon, converting ammonia to ammonium, and reducing serum ammonia levels, which helps manage hepatic encephalopathy.

A. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site B. A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically C. A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around D. A client who has severe head injuries, respiratory rate 6/min, and is unresponsive

Correct Answer is A

Explanation

A. An open chest wound with a hissing sound indicates a sucking chest wound causing a potential tension pneumothorax, which is life-threatening but potentially reversible with immediate intervention—this client requires immediate priority.
B. Simple fractures and superficial injuries are less urgent and can wait.
C. A stable pregnant client who is ambulatory with minor injuries is lower priority.
D. Severe head injury with a very low respiratory rate and unresponsiveness indicates a poor prognosis; in mass casualty triage, this client may be categorized as expectant (lowest priority for immediate intervention).

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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

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