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 C
Explanation
A. Feeling fatigued is not indicative of a therapeutic response; rather, patients should experience increased energy levels with appropriate therapy.
B. Decreased thyroxine levels are not the primary goal of levothyroxine therapy, which aims to normalize thyroid hormone levels in the body.
C. Decreased thyroid-stimulating hormone (TSH) levels indicate that the body is responding well to levothyroxine, as TSH production decreases when thyroid hormone levels are adequate.
D. Bradycardia and hypotension are not desired effects of levothyroxine and indicate potential under-treatment or other issues rather than a therapeutic response.
Correct Answer is A
Explanation
A. Chvostek's sign, a facial muscle spasm upon tapping, is a clinical indicator of hypocalcemia, often caused by accidental removal or damage to the parathyroid glands during thyroid surgery.
B. Hypercalcemia does not typically cause a positive Chvostek’s sign.
C. Hypokalemia affects muscle and cardiac function but does not result in a positive Chvostek’s sign.
D. Hyponatremia does not produce Chvostek's sign, which is specific to hypocalcemia.