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A nurse is caring for a client who has quadriplegia due to a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. What should the nurse prioritize as the initial action?

A.

Lower the client's legs.

B.

Check for a full bladder.

C.

Administer a nitrate antihypertensive.

D.

Administer pain medication.

Answer and Explanation

The Correct Answer is B

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.


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View Related questions

Correct Answer is A

Explanation

A. Baked fish is rich in iodine, which supports thyroid function and can be beneficial for clients with hypothyroidism. Iodine is necessary for thyroid hormone production.

B. Tuna salad may contain iodine, but it is not as reliable a source as baked fish and may also contain added fats.

C. Bran flakes are high in fiber, which can interfere with the absorption of thyroid medications.

D. Cantaloupe, while nutritious, does not provide significant levels of iodine or nutrients that directly support thyroid function.

Correct Answer is A

Explanation

A. Elevated PTH levels lead to increased calcium reabsorption from bones and enhanced calcium absorption in the kidneys, which can result in hypercalcemia and increase the risk of renal calculi (kidney stones).

B. Irritability and anxiety are not directly associated with high PTH levels. They are more often linked to thyroid hormone imbalances.

C. Frequent diarrhea is not a common symptom of elevated PTH levels; instead, hypercalcemia can lead to constipation.

D. Tetany and muscle pain are more commonly associated with low calcium levels, such as in hypoparathyroidism, not elevated PTH.

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