A client with an incomplete spinal cord injury is being transferred from intensive care to the neurological trauma unit

Question

The nurse realizes that in order to minimize the risk of the client developing autonomic hyperreflexia, the following interventions should be included in the client's care plan: Select all that apply. 1. Bladder scan post-voiding
2. Strict output monitoring
3. Assessing for abdominal distention
4. Monitoring skin temperature in lower extremities
5. Assessing pulse oximetry levels with vitals

Answer 1

1. Bladder scan post-voiding
2. Strict output monitoring
3. Assessing for abdominal distention

Rationale: Bladder scan post-voiding. The nurse should be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI) clients in order to prevent the chain of events that leads to autonomic hyperreflexia. Scan the bladder post-voiding to determine the presence of residual urine retention. Strict output monitoring. Track urinary output carefully to determine the presence of residual urine retention. Assessing for abdominal distention. Causes of autonomic hyperreflexia are impacted stool or constipation, so assessing for abdominal distention is appropriate. Monitoring skin temperature in lower extremities. Monitoring lower extremity skin temperature is appropriate for detecting deep vein thrombosis. Assessing pulse oximetry levels with vitals. Pulse oximetry is effective in monitoring for a decline in oxygen saturation and may be the initial indicator of a pulmonary emboli.