The nurse observing a client with autonomic dysreflexia would expect which of the following clinical manifestations?

Tachycardia and hypertension

Bradycardia and hypertension

Bradycardia and hypotension

Tachycardia and hypotension

Answer and Explanation

The Correct Answer is B

A. Tachycardia does not occur with autonomic dysreflexia.

B. Autonomic dysreflexia is a life-threatening condition caused by a noxious stimulus (e.g., full bladder, constipation) in patients with spinal cord injuries above T6. It leads to severe hypertension and reflex bradycardia.

C. Hypotension is not a symptom; autonomic dysreflexia causes hypertension.

D. Tachycardia and hypotension are more associated with spinal shock rather than autonomic dysreflexia.

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Correct Answer is A

Explanation

A. Obtain the patient's blood glucose level between 2a.m-4a.m – Correct Answer. The Somogyi effect occurs when nighttime hypoglycemia triggers a rebound hyperglycemia in the morning. Checking the blood glucose level during the early morning hours helps confirm this phenomenon.

B. Check the patient for a change in level of consciousness between 2a.m-4a.m – Incorrect. While severe hypoglycemia can affect consciousness, the best way to confirm the Somogyi effect is through blood glucose monitoring.

C. Withhold the nighttime snack and check the glucose at 6:00 a.m. – Incorrect. A nighttime snack can help prevent the hypoglycemia that leads to the Somogyi effect.

D. Administer an increased dose of NPH insulin in the evening. – Incorrect. Increasing insulin could worsen nighttime hypoglycemia, making the Somogyi effect worse.

A. Impaired immunity B. Hypoxia C. Fluid retention D. Prolonged bleeding

Correct Answer is B

Explanation

A. Impaired immunity. – Incorrect. While anemia may weaken overall health, hemoglobin levels of 10 g/dL do not significantly affect immune function.

B. Hypoxia. – Correct Answer. Hemoglobin carries oxygen in the blood, and low levels can lead to decreased oxygen delivery to tissues, causing hypoxia.

C. Fluid retention. – Incorrect. Anemia does not directly cause fluid retention.

D. Prolonged bleeding. – Incorrect. While severe anemia can be associated with bleeding disorders, a hemoglobin level of 10 g/dL does not significantly impair clotting.

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The nurse observing a client with autonomic dysreflexia would expect which of the following clinical manifestations?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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