The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

Elevate the head of the bed, loosen clothing, and check the urinary catheter for obstruction

Elevate the head of the bed and apply a cool compress to the forehead

Place in Semi-Fowler's position and establish IV access

Establish IV access, apply 2 liters of nasal oxygen, and contact the health care provider

Answer and Explanation

The Correct Answer is A

A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.

B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.

C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.

D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Timolol is a beta-blocker that can be absorbed systemically, leading to side effects such as bradycardia and hypotension, which require monitoring.

B. Tachycardia and dry cough are not common side effects of timolol; dry cough is more associated with ACE inhibitors.

C. Scleral injection and tearing are not common side effects and are not expected with timolol use.

D. Changes in eye pigmentation are more commonly seen with prostaglandin analogs, not with beta-blockers like timolol.

A. "Using three drugs at the same time enhances suppression of viral replication." B. "If the virus becomes resistant to this combination, I will be switched to another combination of medications." C. "Because the combination of medications kills the virus, I can stop taking the medications." D. "My CD4 count should increase with this medication regimen."

Correct Answer is C

Explanation

A. This is a correct statement, as using multiple drugs helps to reduce the likelihood of resistance and enhances viral suppression.

B. This is accurate; if resistance develops, alternative medications or combinations can be considered.

C. This statement indicates a misunderstanding. Antiretroviral medications do not kill the virus; they suppress its replication. Lifelong adherence to antiretroviral therapy is necessary to manage HIV and prevent viral rebound.

D. Correct, as an effective regimen should lead to an increase in CD4 count and improved immune function.

View Question and Answer

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

The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The provider has prescribed timolol ophthalmic drops for the patient diagnosed with glaucoma. The nurse should assess the patient for which of the following side effects?

Correct Answer is A

Explanation

Which statement made by a patient who is diagnosed with human immunodeficiency virus (HIV) and is prescribed three antiretroviral medications, indicates the need for further teaching about the medication combination?

Correct Answer is C

Explanation

The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

The nurse is performing the morning assessment on a patient. The patient suddenly screams loudly and begins to have a generalized tonic/clonic type seizure. What is the priority nursing intervention?

The nurse is caring for a patient with a complete spinal cord injury at the level of C7. Which intervention would the nurse implement in order to prevent complications related to immobility?

A nurse is assigned a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which type of precaution should be used when providing direct care?

The nurse is educating on the placement of a ventriculostomy (intraventricular catheter) to the patient diagnosed with a brain injury and their family. The nurse states, "The ventriculostomy is placed:

The nurse teaches a patient diagnosed with Bell's Palsy about the use of an eye patch to prevent which eye complication?

The nurse suspects a subarachnoid hemorrhage in a patient admitted to the emergency department. Which of the following symptoms is commonly seen in a patient diagnosed with a subarachnoid hemorrhage?

A nurse is preparing to administer clonidine 0.3 mg at bedtime to a patient. The amount available is clonidine 0.1 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)