Nur 1700 Q6 Randoms Exam Questions (92 Terms) With Verified Definitions Updated 2024

The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take? 1. raise the head of the bed and remove the noxious stimulus 2. lower the head of the bed and remove the noxious stimulus 3. lower the head of the bed and administer an antihypertensive agent {Ans: 1. raise the head of the bed and remove the noxious stimulus}The nurse is watching for indications of autonomic dysreflexia in a client who sustained a spinal cord injury in a fall from a roof. Which sign/symptom of this complication should the nurse monitor closely? Constricted pupils Tachycardia Hypotension Nasal stuffiness {Ans: Nasal stuffiness RATIONALE:Autonomic dysreflexia, a complication of spinal cord injury, is a neurological emergency and must be treated immediately to prevent hypertensive stroke. It generally occurs after spinal shock resolves in the presence of injuries above T6 and in cervical lesions. It is commonly caused by visceral distention resulting from bladder distention or fecal impaction. Clinical manifestations include sudden onset of severe throbbing headache, severe hypertension, bradycardia, flushing above the level of injury, pale extremities below the level of injury, nasal stuffiness, nausea, dilated pupils,