The nurse in the emergency department is caring for a client who sustained a spinal cord injury at T4. The nurse should recognize that the client is at risk for developing

neurogenic shock

malignant hyperthermia

neuroleptic malignant syndrome

tardive dyskinesia

Answer and Explanation

The Correct Answer is A

A. Neurogenic shock is a common complication of spinal cord injuries above T6, including T4, due to disruption of sympathetic pathways causing hypotension, bradycardia, and vasodilation.
B. Malignant hyperthermia is a rare genetic reaction to certain anesthetics, unrelated to spinal cord injury.
C. Neuroleptic malignant syndrome is a reaction to antipsychotic drugs, not related to spinal cord injury.
D. Tardive dyskinesia is a side effect of long-term antipsychotic use, unrelated to spinal cord injury.

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Correct Answer is C

Explanation

A. Bladder distention is a common trigger of autonomic dysreflexia, but the immediate priority is to reduce blood pressure by positioning the patient.
B. Antihypertensive medication may be necessary, but nonpharmacologic interventions such as positioning and removing the triggering stimulus should be done first.
C. Placing the client in a high-Fowler’s position is the first action to lower blood pressure by promoting venous pooling in the lower extremities, thereby reducing cerebral blood pressure and minimizing the risk of stroke.
D. Heart rate monitoring is part of the assessment but does not take priority over immediately addressing the dangerously high blood pressure.

A. Administer PRN analgesic medication B. Lower the head of the bed C. Palpate the client's bladder D. Administer PRN antihypertensive medication

Correct Answer is C

Explanation

A. Analgesics address pain but do not treat the underlying cause of symptoms.
B. Lowering the head of the bed can increase intracranial pressure and worsen hypertension in autonomic dysreflexia.
C. Bladder distention is a common trigger of autonomic dysreflexia; assessing and relieving bladder distention is the priority intervention.
D. Antihypertensive medication may be necessary but only after removing the triggering cause to avoid sudden drops in blood pressure.

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The nurse in the emergency department is caring for a client who sustained a spinal cord injury at T4. The nurse should recognize that the client is at risk for developing

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially?

Correct Answer is C

Explanation

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