The nurse suspects that a patient with spinal cord injury (SCI) is experiencing autonomic dysreflexia. The nurse elevates the head of the bed and removes the patient's compression stockings while searching for the cause of this response
Performing these interventions helps to avoid which very dangerous complication of autonomic dysreflexia? 1. Hypoxia
2. Bradycardia
3. Elevated blood pressure
4. Tachycardia
3
Rationale 1: Hypoxia is not the most dangerous complication of autonomic dysreflexia.
Rationale 2: Bradycardia may occur but is not the most immediately dangerous complication.
Rationale 3: Autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. Additional nursing assistance will be needed and a colleague needs to reach the physician stat.
Rationale 4: Tachycardia is not the most common complication.
You might also like to view...
Which statement describes correct guidelines for setting up medications?
A. Follow aseptic procedure when handling medications. B. If preparing a unit-dose tablet, place the tablet directly into the medicine cup. C. Clear your mind of everything. The task at hand needs your full attention. D. All answers are correct.
A client complains of nausea and vomiting. Which medication would not be prescribed for this client?
1. Diphenoxylate with atropine (Lomotil) 2. Prochlorperazine (Compazine) 3. Promethazine (Phenergan) 4. Ondansetron (Zofran)
A demand management system is a better predictor of staff than patient classification systems. The demand management system focuses on:
1. Immediate client needs. 2. Historical data of expected client outcomes. 3. Allocation of staff throughout the organization. 4. Nursing care hours.
The nurse is providing discharge instructions for a client who will be going home following tympanoplasty surgery. Which statement by the client indicates that additional teaching is needed?
a. "I will wear earplugs whenever I am in noisy areas." b. "I will occlude only one nostril when I blow my nose." c. "I will wait 3 weeks before I resume my aerobics workouts." d. "I will use a cotton swab to clean drainage from inside my ear."