A nurse is assessing a client with autonomic dysreflexia. The nurse correlates which clinical manifestations to autonomic dysreflexia in a client with a spinal cord injury?
Hypertension with bradycardia
Hypotension with tachycardia
Hypertension with tachycardia
Hypotension with bradycardia
The Correct Answer is A
A. Hypertension with bradycardia is characteristic of autonomic dysreflexia due to the exaggerated sympathetic response causing increased blood pressure while the body compensates with bradycardia.
B. Hypotension with tachycardia is not indicative of autonomic dysreflexia; instead, it suggests different underlying issues.
C. While hypertension can occur in autonomic dysreflexia, it is typically accompanied by bradycardia, not tachycardia.
D. Hypotension with bradycardia does not correlate with autonomic dysreflexia and suggests other health complications.
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Correct Answer is A
Explanation
A. Assessing respiratory status and airway patency is the highest priority in this situation due to the risk of respiratory compromise from cervical spinal cord injuries, which can affect the diaphragm and other respiratory muscles.
B. While assessing extremity strength and sensation is important, it comes after ensuring the client’s airway and breathing are stable.
C. Pain management is essential, but addressing immediate life-threatening conditions takes precedence over pain assessment.
D. Assessing the client's level of consciousness is crucial for overall evaluation but does not take priority over ensuring adequate respiratory function in the context of a cervical spinal cord injury.
Correct Answer is B
Explanation
A. Lowering the client's legs is not effective in managing autonomic dysreflexia and may not alleviate the cause of the high blood pressure.
B. Checking for a full bladder is the priority because bladder distension is a common trigger for autonomic dysreflexia in clients with spinal cord injuries, and relieving it can reduce the severe hypertensive response.
C. Antihypertensives may be used if non-pharmacological measures fail, but addressing the cause is the first action.
D. Pain medication is not indicated as the immediate intervention for autonomic dysreflexia, as the priority is identifying and removing the trigger.