The nurse is caring for a client with a spinal cord injury. The client exhibits signs of autonomic hyperreflexia. What does the nurse recall is the most common cause of this response? Show 3 rationale: The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period? 1 rationale: A client who
is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity? 1 rationale: A nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Why is this necessary? 3 rationale: After a client is treated for a spinal cord injury, the healthcare provider informs the family that the client is a paraplegic. The family asks the nurse what this means. Which explanation should the nurse provide? 1 rationale: A young adult client is hospitalized with a spinal cord injury. The
client, knowing that the paralysis may be permanent, says, "I wish God would end my suffering and take me." What is the most therapeutic initial response by the nurse? 2 rationale: The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem? 4 rationale: Which
responses should alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia? 4 rationale: A client who sustained a spinal cord injury experienced an episode of autonomic dysreflexia. Which intervention should the nurse perform first? 2 rationale: The nurse is providing care to a client with a neck and spinal cord injury. Which is the priority when moving this client during the assessment process? 3 rationale: The nurse finds that a client with a spinal
cord injury has developed sudden autonomic dysreflexia. What is the priority nursing action in this situation? 1 rationale: A nurse is
caring for a client with a spinal cord injury during the immediate postinjury period. Which is the priority focus of nursing care during this immediate phase? 3 rationale: A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic
hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment? 2 rationale: The nurse is caring for a client
with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia (autonomic dysreflexia)? 1 rationale: A young man who sustained a spinal cord injury at the cervical level expresses concern about sexual functioning. What should the nurse do when counseling this client? 1 rationale: A nurse is caring for a client with a spinal cord injury. What is the specific reason fluid intake should be increased for this client? 3 rationale: The nurse is caring for a client one week after the client experienced a spinal cord injury at the T3 level. What is an appropriate short-term goal for this client? 4 rationale: The nurse is caring for a client in active labor with a history of T5 spinal cord injury. Which of the following
findings indicates to the nurse that the client is experiencing a complication of the labor process? 3 rationale: A nurse in the emergency department is caring for a 9-year-old child with a suspected spinal cord injury sustained while falling off a bicycle. What is the
initial nursing action? 2 rationale: A preschool child with a spinal cord injury will be on prolonged bed rest. The nurse explains to the parents that certain foods will be restricted to prevent complications associated with immobility. What food should be noted as
restricted in the teaching plan? 4 rationale: A young adult sustained a spinal cord injury at the level of T5 a week ago and is now incontinent of feces. When the nurse tries to give a bath and change the linens, the client says, "Leave me alone. It's worse having you change me than it is to lie in this mess." What is the best response by the nurse? 4 rationale: A client was admitted to the hospital with a direct injury to the vertebral column from a gunshot after a mass shooting. The nurse suspects a spinal cord injury. Which mechanism of injury might be the reason
for the injury? 4 rationale: The nurse is caring for a client with a spinal cord injury. Which priority intervention should be performed by the nurse immediately? 4 rationale: A client with a spinal cord injury tends to assume the low Fowler position excessively. In which area of the body will the nurse most likely discover a pressure ulcer? 4 rationale: A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? 2 rationale: A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include? 2 rationale: A client who was in a traffic accident is choking. The nurse suspects that the client may have a spinal cord injury. Which procedure may benefit the
client? 3 rationale: A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should
monitor the client for what clinical manifestations of spinal shock? Select all that apply. 1, 2, 4 rationale: Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffee-ground material and appears restless and
apprehensive. What is the most important initial nursing action? 3 rationale: A client
has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply. 3, 5 rationale: What is the best position for a patient experiencing autonomic dysreflexia?What is the BEST position for a patient experiencing autonomic dysreflexia? The answer is A. The patient should be in high Fowler's (90 degrees) with the legs lowered. This will allow gravity to cause blood to pool in the lower extremities and help decrease blood pressure.
What to do if a patient is experiencing autonomic dysreflexia?If you have autonomic dysreflexia symptoms, here are a few things you can do until you can get medical help:. Sit up as much you can. This helps move more blood to your lower body and ease your blood pressure.. Take off tight clothes or other irritants.. What is autonomic dysreflexia in spinal cord injury?What is autonomic dysreflexia? Autonomic dysreflexia is the product of dysregulation of the autonomic system, leading to an uncoordinated response to a noxious stimulus below the level of a spinal cord injury,2 usually in individuals with a spinal cord injury above the level of T6 (fig 1).
What is the emergency treatment for autonomic dysreflexia?Nitroglycerine 2% paste is the recommended initial emergency treatment of severe hypertension in patients with autonomic dysreflexia. [30] One to two inches of nitroglycerine 2% paste should be placed on the skin above the level of the spinal cord injury.
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