You are caring for a paraplegic who suddenly becomes nauseous, dizzy, and restless. He reports a headache and appears to be sweating and flushed. What is the major concern?
What will be an ideal response?
Autonomic hyperreflexia—this autonomic nervous system overreaction to stimulus can be life threatening. It can elevate blood pressure and lead to stroke, seizure, heart attack, and even death.
You might also like to view...
A 16-year-old girl is being seen at the clinic for gastrointestinal complaints and weight loss. The nurse determines that many of her complaints may be related to erratic eating patterns, eating predominantly fast foods, and high caffeine intake
In this situation, which is most appropriate when collecting current dietary intake information? a. Scheduling a time for direct observation of the adolescent during meals b. Asking the patient for a 24-hour diet recall, and assuming it to be reflective of a typical day for her c. Having the patient complete a food diary for 3 days, including 2 weekdays and 1 weekend day d. Using the food frequency questionnaire to identify the amount of intake of specific foods
Variable FHR decelerations are caused by:
1. altered fetal cerebral blood flow. 2. umbilical cord compression. 3. uteroplacental insufficiency. 4. fetal hypoxemia.
The client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which of the following actions are planned to promote client safety? Select all that apply
1. Monitor potassium levels. 2. Monitor for symptoms of fluid retention. 3. Provide the client with a soft toothbrush. 4. Instruct the client to use an electric razor. 5. Weigh client daily, and monitor trends. 6. Monitor all secretions for frank or occult blood.
When the medication nurse offers a pill to the older adult patient, the patient asks, "What is this and what is it for?" The nurse's best response would be:
a. "I am not at liberty to discuss your medication. You need to talk to your doctor." b. "That is a ‘feel good' pill that will make you feel better." c. "It is a cephalosporin that has been ordered to treat your URI." d. "It is an antibiotic for the infection in your urine."