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.

Answer and Explanation

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:.

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Correct Answer is B

Explanation

The correct answer isB.

Loss of muscle mass and strength.Sarcopenia is a condition that affects older adults and causes a progressive decline in skeletal muscle mass, strength, and function.This can lead to an increased risk of falls, fractures, disability, and mortality.

Choice A is wrong because the loss of bone mass and strength is calledosteoporosis, not sarcopenia.Osteoporosis is a condition that affects the density and quality of bones, making them more prone to fracture.

Choice C is wrong because loss of joint flexibility and range of motion is calledarthritis, not sarcopenia.

Arthritis is a term that refers to inflammation of the joints, which can cause pain, stiffness, swelling, and reduced mobility.

Choice D is wrong because loss of skin elasticity and moisture is calledskin aging, not sarcopenia.

Skin aging is a process that involves changes in the structure and function of the skin, such as wrinkles, sagging, dryness, and decreased wound healing.

Normal ranges for muscle mass and strength vary depending on age, sex, body size, and physical activity level.However, some general indicators of sarcopenia include:.

• A muscle mass index (muscle mass divided by height squared) below 7.26 kg/m2 for men and 5.45 kg/m2 for women.

• A handgrip strength below 30 kg for men and 20 kg for women.

• A gait speed below 0.8 m/s for both sexes.

A. Muscle atrophy and fasciculations. B. Intention tremors and nystagmus. C. Flaccid paralysis and areflexia. D. Hyperactive reflexes and spasticity.

Correct Answer is B

Explanation

Intention tremors and nystagmus.These are some of the common symptoms of multiple sclerosis (MS), a condition that affects the central nervous system and causes communication problems between the brain and the rest of the body.Intention tremors are involuntary shaking movements that occur when a person tries to perform a precise action, such as reaching for an object or writing.Nystagmus is a condition where the eyes make repetitive, uncontrolled movements, often resulting in reduced vision and depth perception.

Choice A is wrong because muscle atrophy and fasciculations are more typical of motor neuron diseases, such as amyotrophic lateral sclerosis (ALS), which affect the nerve cells that control voluntary muscle movements.

Choice C is wrong because flaccid paralysis and areflexia are signs of lower motor neuron lesions, which can be caused by spinal cord injuries, peripheral nerve disorders, or Guillain-Barré syndrome.

Choice D is wrong because hyperactive reflexes and spasticity are signs of upper motor neuron lesions, which can be caused by stroke, traumatic brain injury, or cerebral palsy.

Normal ranges for some of the symptoms mentioned are:.

• Intention tremors: none or minimal.

• Nystagmus: none or minimal.

• Muscle atrophy: none or minimal.

• Fasciculations: none or minimal.

• Flaccid paralysis: none or minimal.

• Areflexia: absent or reduced reflexes.

• Hyperactive reflexes: normal or slightly increased reflexes.

• Spasticity: normal or slightly increased muscle tone.

A. Muscle atrophy and fasciculations B.

Intention tremors and nystagmus C.

Flaccid paralysis and areflexia D.

Hyperactive reflexes and spasticity

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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?

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A nurse is assessing an older adult client who has sarcopenia. The nurse knows that this condition is characterized by which of the following?

Correct Answer is B

Explanation

The nurse is assessing a patient who has been diagnosed with multiple sclerosis (MS). Which of the following findings is most consistent with this condition?

Correct Answer is B

Explanation

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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?