Your spinal cord injury (SCI) patient complains of a throbbing headache and nausea. You observe the patient has marked diaphoresis, and you think the patient may have autonomic dysreflexia. Place the following interventions in the order you would complete them.
Check the blood pressure
Obtain a bladder scan
Notify the doctor
Elevate the head of the bed to 45 degrees
The Correct Answer is D,A,B,C
Choice D reason: Elevating the head of the bed to 45 degrees is the first intervention the nurse should perform. This position helps lower the patient's blood pressure by promoting venous pooling in the lower extremities and reducing the return of blood to the heart. It also aids in better breathing and overall comfort.
Choice A reason: Checking the blood pressure is crucial in this situation to confirm if the patient is experiencing autonomic dysreflexia, which is characterized by a sudden and severe increase in blood pressure. This step helps in assessing the severity of the condition and guiding subsequent interventions.
Choice B reason: Obtaining a bladder scan is important because a full bladder is a common trigger of autonomic dysreflexia. By identifying and addressing the cause of the distension, the nurse can help alleviate the symptoms and prevent further complications.
Choice C reason: Notifying the doctor is a critical step, as autonomic dysreflexia is a medical emergency that requires prompt medical intervention. The healthcare provider can give additional orders and may administer medication to control the patient's blood pressure and relieve symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Fluid volume overload is not typically associated with diabetes insipidus. Instead, patients with diabetes insipidus often experience fluid volume deficit due to excessive urine output.
Choice B reason: Hyperglycemia is not a characteristic problem of diabetes insipidus. This condition involves an imbalance in water regulation due to insufficient production or response to antidiuretic hormone (ADH), rather than issues related to blood glucose levels.
Choice C reason: Nocturia, or frequent urination at night, is a common problem in diabetes insipidus. Patients with this condition produce large amounts of dilute urine, which can lead to frequent nighttime urination.
Choice D reason: Generalized edema is not a typical problem in diabetes insipidus. Edema is more commonly associated with conditions involving fluid retention, such as heart failure or kidney disease, rather than the excessive fluid loss seen in diabetes insipidus.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Dementia is not a typical complication directly related to the post-operative period of a total hip replacement. While elderly patients may have underlying cognitive issues, dementia is not considered a direct post-op complication.
Choice B reason: Venous thromboembolism (VTE) is a common post-operative complication, particularly in orthopedic surgeries like total hip replacement. Due to immobility and surgical stress, patients are at higher risk for blood clots forming in the veins, which can be life-threatening if they travel to the lungs.
Choice C reason: Fluid overload can occur due to the administration of intravenous fluids during surgery. Monitoring for signs of fluid overload, such as swelling, shortness of breath, and increased blood pressure, is crucial to ensure proper fluid balance and prevent complications like heart failure.
Choice D reason: Infection is a significant risk after surgery, especially in procedures like total hip replacement. Monitoring for signs of infection, such as fever, increased pain, redness, swelling, and drainage from the surgical site, is essential to detect and treat infections early.
Choice E reason: Unrelieved pain is a critical aspect to monitor post-operatively. Effective pain management is crucial for patient comfort, mobility, and recovery. Uncontrolled pain can impede rehabilitation and recovery, increasing the risk of complications.
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