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?
Lower the client's legs.
Check for a full bladder.
Administer a nitrate antihypertensive.
Administer pain medication.
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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Correct Answer is B
Explanation
A. Low levels of PTH would primarily affect calcium metabolism and would not directly explain short stature or delayed menarche.
B. Impaired production of GH is most likely the cause of short stature, as growth hormone plays a critical role in growth and development during childhood.
C. Lack of ACTH affects adrenal hormone production but does not directly lead to short stature or delayed menarche.
D. Impaired production of T3 and T4 would affect metabolism and growth but is less likely to be the primary cause of the symptoms presented compared to growth hormone deficiencies.
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.