Question: A nurse is caring for a client with a spinal cord injury at the T6 level. The client suddenly develops a severe headache, profuse sweating, and elevated blood pressure. The nurse should prioritize which intervention? A) Administering a pain reliever B) Elevating the client’s legs C) Checking for a full bladder D) Administering an antipyretic E) Providing a warm blanket
Correct Answer: C) Checking for a full bladder
Rationale: In clients with spinal cord injuries at T6 or above, autonomic dysreflexia can be triggered by a full bladder. The priority is to identify and address the cause of dysreflexia, which in this case is likely due to bladder distention. Checking for a full bladder and relieving it can help alleviate the symptoms and prevent further complications associated with autonomic dysreflexia.
@qbankproacademy 4000+ Free NCLEX QUESTIONS. Go to QBankProAcademy.com FREE Qbank questions for NCLEX RN, PN, HESI Exit, Med Surg, AANP, ANCC, and HesiA2. Practice questions, quizzes, and listen to the Free Podcast. In this video, we review a question on AUTONOMIC DYSREFLEXIA Nursing Care. At QbankproAcademy.com our mission is to provide free QBanks, videos, and the most up to date test prep information for nurses. If you find our website helpful, please tell other aspiring nurses, nursing students, and professors. Please link to our site from your blogs, videos, and college websites, or share us on your favorite social media sites. Thank you for your support! Free nursing NCLEX 60-DAY CHALLENGE https://qbankpro.thinkific.com/courses/qbankpro-academy nclex Nurses Nursing aanp qbank ancc hesi medsurg qbank
Understanding Autonomic Dysreflexia: NCLEX Delegation Questions
Question: A client with a history of spinal cord injury is admitted to the hospital. During the assessment, the nurse notes flushing above the level of the injury and cool, pale skin below the injury. The client complains of a pounding headache. What action should the nurse take first? A) Administering a vasodilator B) Encouraging increased fluid intake C) Notifying the healthcare provider D) Elevating the client’s legs E) Administering an antianxiety medication
Correct Answer: C) Notifying the healthcare provider
Rationale: Flushing above the level of injury and cool, pale skin below are indicative of autonomic dysreflexia. Notifying the healthcare provider is crucial for prompt intervention and management. The healthcare provider can assess the situation, order appropriate interventions, and address the underlying cause of autonomic dysreflexia.
Understanding Autonomic Dysreflexia: Causes and Symptoms
Question: A nurse is caring for a client with autonomic dysreflexia. The client reports a sudden onset of severe hypertension and a throbbing headache. Which intervention should the nurse prioritize? A) Administering a diuretic B) Elevating the client’s legs C) Checking for a full bladder D) Administering a beta-blocker E) Providing a cool compress
Correct Answer: C) Checking for a full bladder
Rationale: Autonomic dysreflexia can be triggered by various stimuli, and one common cause is a full bladder. Checking for a full bladder is a priority to identify and address the trigger, leading to a reduction in symptoms and preventing further complications associated with autonomic dysreflexia.
NCLEX Practice Questions: Understanding Autonomic Dysreflexia Causes and Symptoms
Question: A client with a history of spinal cord injury presents with symptoms of autonomic dysreflexia, including severe hypertension and flushing. What should the nurse do first? A) Administering a vasodilator B) Encouraging increased fluid intake C) Elevating the client’s legs D) Checking for a full bladder E) Administering an antianxiety medication
Correct Answer: D) Checking for a full bladder
Rationale: In clients with autonomic dysreflexia, checking for a full bladder is a priority. Bladder distention is a common trigger for dysreflexia, and addressing the underlying cause is essential for symptom relief and preventing complications. Identifying and resolving the trigger, such as a full bladder, is the first step in managing autonomic dysreflexia effectively.
Understanding Autonomic Dysreflexia: Causes and Symptoms
Question: A client with autonomic dysreflexia presents with elevated blood pressure, pounding headache, and sweating. What intervention should the nurse prioritize? A) Administering a diuretic B) Elevating the client’s legs C) Checking for a full bladder D) Administering a beta-blocker E) Providing a cool compress
Correct Answer: D) Administering a beta-blocker
Rationale: Administering a beta-blocker is appropriate in cases of severe hypertension associated with autonomic dysreflexia. This medication helps lower blood pressure by blocking the effects of adrenaline. While checking for a full bladder is crucial in dysreflexia, addressing the immediate hypertensive response with a beta-blocker is essential for preventing complications such as stroke or seizures.
Understanding Autonomic Dysreflexia: NCLEX Priority Questions
Question: A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly experiences a pounding headache, profuse sweating, and elevated blood pressure. The nurse should prioritize which action? A) Administering an opioid analgesic B) Providing a warm blanket C) Checking for a full bladder D) Administering an antipyretic E) Elevating the client’s legs
Correct Answer: C) Checking for a full bladder
Rationale: Autonomic dysreflexia in clients with spinal cord injuries above T6 can be triggered by a full bladder. Checking for a full bladder is crucial as it is a common cause of autonomic dysreflexia. Addressing the bladder distention promptly can alleviate the symptoms and prevent further complications associated with dysreflexia.
Question: A client with a history of spinal cord injury is admitted to the hospital. During the assessment, the nurse notes flushing above the level of the injury and cool, pale skin below the injury. The client complains of a pounding headache. What action should the nurse take first? A) Administering a vasodilator B) Encouraging increased fluid intake C) Notifying the healthcare provider D) Elevating the client’s legs E) Administering an antianxiety medication
Correct Answer: C) Notifying the healthcare provider
Rationale: Flushing above the level of injury and cool, pale skin below indicate autonomic dysreflexia. Notifying the healthcare provider is essential for prompt intervention and management. The healthcare provider can assess the situation, identify the cause, and order appropriate interventions to address autonomic dysreflexia.
NCLEX Review: Autonomic Dysreflexia Treatments
Question: A nurse is caring for a client with autonomic dysreflexia. The client reports a sudden onset of severe hypertension and a throbbing headache. Which intervention should the nurse prioritize? A) Administering a diuretic B) Elevating the client’s legs C) Checking for a full bladder D) Administering a beta-blocker E) Providing a cool compress
Correct Answer: C) Checking for a full bladder
Rationale: In autonomic dysreflexia, checking for a full bladder is a priority. Bladder distention is a common trigger for dysreflexia, and addressing the underlying cause is essential for symptom relief and preventing complications associated with autonomic dysreflexia.
Question: A client with autonomic dysreflexia presents with elevated blood pressure, pounding headache, and sweating. What intervention should the nurse prioritize? A) Administering a diuretic B) Elevating the client’s legs C) Checking for a full bladder D) Administering a beta-blocker E) Providing a cool compress
Correct Answer: D) Administering a beta-blocker
Rationale: Administering a beta-blocker is appropriate in cases of severe hypertension associated with autonomic dysreflexia. This helps lower blood pressure by blocking the effects of adrenaline, addressing the immediate hypertensive response and preventing complications such as stroke or seizures. While checking for a full bladder is important, addressing the hypertensive crisis is a priority in this situation.
NCLEX Questions: Focus on Medications for Autonomic Dysreflexia
Question: A nurse is caring for a client with a spinal cord injury at the T5 level. The client suddenly experiences a severe headache, flushing above the level of the injury, and cool, pale skin below the injury. What should the nurse do first? A) Administering an analgesic B) Checking for a full bladder C) Elevating the client’s legs D) Applying a warm compress E) Administering an antipyretic
Correct Answer: B) Checking for a full bladder
Rationale: Autonomic dysreflexia in clients with spinal cord injuries above T6 can be triggered by stimuli such as a full bladder. Checking for a full bladder is crucial as it is a common cause of autonomic dysreflexia. Addressing the bladder distention promptly can alleviate symptoms and prevent further complications associated with dysreflexia.
Question: A client with autonomic dysreflexia presents with severe hypertension, headache, and diaphoresis. What intervention should the nurse prioritize? A) Administering a diuretic B) Elevating the client’s legs C) Checking for a full bladder D) Administering a vasodilator E) Providing a warm blanket
Correct Answer: D) Administering a vasodilator
Rationale: Administering a vasodilator is appropriate in cases of severe hypertension associated with autonomic dysreflexia. This medication helps dilate blood vessels, reducing blood pressure. While checking for a full bladder is important, addressing the hypertensive crisis is a priority in this situation to prevent complications such as stroke or seizures. Administering a vasodilator can effectively manage the elevated blood pressure associated with autonomic dysreflexia.
