The nurse is caring for a patient who has had a spinal cord injury at level C5-C6 as a result of an automobile accident. The patient suddenly develops severe hypertension, throbbing headache, blurred vision, and bradycardia.
What is the priority nursing intervention?
Administer antihypertensive medication as prescribed.
Elevate the head of bed to 90 degrees.
Check for bladder distention or fecal impaction.
Apply a cooling blanket to lower body temperature.
The Correct Answer is C
The correct answer is C.
Check for bladder distention or fecal impaction.
Autonomic dysreflexia is a disorder of autonomic nervous system dysregulation that occurs in patients with a spinal cord injury above T6.
It is caused by an exaggerated reflex response of the sympathetic nervous system due to an irritating stimulus below the spinal cord injury. It leads to severe hypertension and is a medical emergency.
Bladder or bowel distension are the most common triggers of autonomic dysreflexia.
Therefore, the priority nursing intervention is to check for bladder distention or fecal impaction and relieve them as soon as possible.
This can help to eliminate the stimulus and lower the blood pressure.
Choice A is wrong because administering antihypertensive medication as prescribed may not be effective or appropriate for autonomic dysreflexia.
The hypertension is caused by a reflex mechanism and not by a primary cardiovascular disorder. Moreover, antihypertensive drugs may cause hypotension once the stimulus is removed.
Choice B is wrong because elevating the head of bed to 90 degrees may not be enough to lower the blood pressure. It may also increase the risk of orthostatic hypotension once the stimulus is removed. However, sitting the patient upright and loosening any tight clothing are recommended as initial steps to reduce the blood pressure.
Choice D is wrong because applying a cooling blanket to lower body temperature is not indicated for autonomic dysreflexia. There is no evidence that body temperature is elevated or contributes to the hypertension in this condition. A cooling blanket may also cause vasoconstriction and worsen the hypertension.
Normal ranges for blood pressure vary depending on age, sex, and other factors.
However, a general guideline is that systolic blood pressure should be less than 120 mm Hg and diastolic blood pressure should be less than 80 mm Hg for most adults.
Normal ranges for heart rate also vary depending on age, activity level, and other factors.
However, a general guideline is that resting heart rate should be between 60 and 100 beats per minute for most adults.
References:.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B.
Older adults may experience changes in sexual response or function due to physiological factors.This is because aging can affect the sex organs, hormones, blood flow, and nerve signals that are involved in sexual arousal and performance.These changes do not mean that older adults cannot enjoy a satisfying sex life, but they may require some adjustments or treatments to overcome any difficulties.
Choice A is wrong because older adults have the same need for intimacy and affection as younger adults, and sexuality is an important component of emotional and physical intimacy that can enhance well-being and quality of life.
Choice C is wrong because older adults with chronic diseases or disabilities can still have sexual activity, as long as they are comfortable and safe.They may need to consult with their health care providers about any precautions or modifications they should make to accommodate their conditions.
Choice D is wrong because older adults are not at lower risk for sexually transmitted infections (STIs) than younger adults.In fact, older adults may be more vulnerable to STIs due to lower immune function, thinner vaginal tissues, lack of condom use, and other factors.
Therefore, older adults should practice safe sex and get tested regularly for STIs.
Normal ranges for sexual response or function vary widely depending on the individual, the partner, the situation, and other factors.
There is no one standard or ideal way to experience sexuality and intimacy in older adulthood.The most important thing is to communicate openly with one’s partner and health care provider about any concerns or preferences, and to seek help if needed.
Correct Answer is ["A","B","E"]
Explanation
The correct answer isA, B, and E.
The nurse should instruct the patient to do the following:.
• Trim nails straight across and file edges smoothly.
• Soak nails in warm water before trimming to soften them.
• Report any signs of infection or inflammation around nails.
These are good practices for nail hygiene and health, especially for the elderly who may have dry, brittle or thickened nails.Trimming nails straight across and filing them prevents ingrown nails and reduces the risk of injury or infection.Soaking nails in warm water makes them easier to cut and less likely to crack or split.Reporting any signs of infection or inflammation around nails is important to prevent complications and get appropriate treatment.
Choice C is wrong because using a metal nail file or scissors to cut nails can damage the nail plate and cause splitting or tearing.Choice D is wrong because applying a clear nail polish to protect nails from cracking is unnecessary and may worsen nail health by trapping moisture and bacteria under the polish.
To maintain healthy nails, the elderly should also scrub the underside of their nails with soap and water, moisturize their nails and cuticles, avoid biting or chewing their nails, eat nutritious foods rich in calcium and vitamins B and C, and use sterilized nail grooming tools.
:Fingernail Care for the Elderly - assisting hands-il-wi.com:Fingernails: Do’s and don’ts for healthy nails - Mayo Clinic:Nail Hygiene | CDC - Centers for Disease Control and Prevention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.