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","C","E"]
Explanation
The correct answer is B, C, and E.
Phenytoin (Dilantin) is an anticonvulsant medication that is used to control seizures.
It can have several side effects, some of which are serious and require medical attention.
Here are some explanations for each choice:.
A. Avoid drinking grapefruit juice while taking this medication.
This iswrongbecause grapefruit juice does not interact with phenytoin.However, grapefruit juice can affect the levels of other medications, such as statins, calcium channel blockers, and some antidepressants.
B. Brush your teeth gently with a soft-bristled toothbrush.This isrightbecause phenytoin can causegingival hyperplasia, which is an overgrowth of the gums that can lead to bleeding, infection, and difficulty chewing.
To prevent this, patients should practice good oral hygiene, avoid alcohol and tobacco, and see a dentist regularly.
A. Avoid drinking grapefruit juice while taking this medication B.
Brush your teeth gently with a soft-bristled toothbrush C.
Wear a medical alert bracelet or necklace at all times D.
Stop taking this medication if you develop a rash or fever E.
Have your blood levels checked regularly as directed by your provider
Correct Answer is A
Explanation
The correct answer is A.
HRT can relieve hot flashes, vaginal dryness and mood swings, but it can also increase the risk of breast cancer, stroke and blood clots.This answer is based on the evidence from various studies that have shown the benefits and risks of HRT.
Choice B is wrong because HRT cannot prevent osteoporosis, heart disease and dementia, and it does not cause weight gain, acne and hair loss.These are common misconceptions about HRT that are not supported by scientific research.
Choice C is wrong because HRT does not have a significant effect on sexual function, skin elasticity and memory, and it does not lower the immune system, blood pressure and blood sugar.These are also myths about HRT that have no basis in reality.
Choice D is wrong because HRT can improve sleep quality, energy levels and mood, but it can also cause or worsen headaches, nausea and bloating.These are some of the possible side effects of HRT that vary depending on the type, dose and duration of the therapy.
Normal ranges for estrogen and progesterone levels depend on the stage of menopause, the type of HRT and the individual factors of each woman.
Generally, estrogen levels range from 10 to 50 pg/mL (picograms per milliliter) and progesterone levels range from 0.1 to 25 ng/mL (nanograms per milliliter) in postmenopausal women.
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