Ati lpn med surg exam
Ati lpn med surg exam ( 53 Questions)
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
Autonomic dysreflexia is often triggered by a noxious stimulus, such as bladder distention. Preventing bladder distention by ensuring regular bladder emptying can help prevent the condition.
Elevating the client's head is a response to autonomic dysreflexia but does not prevent it from occurring.
Providing analgesia for headaches addresses a symptom of autonomic dysreflexia but does not prevent it.
Monitoring for elevated blood pressure is important in detecting autonomic dysreflexia once it has started, but it does not prevent it.
A. Autonomic dysreflexia is often triggered by a noxious stimulus, such as bladder distention. Preventing bladder distention by ensuring regular bladder emptying can help prevent the condition.
B. Elevating the client's head is a response to autonomic dysreflexia but does not prevent it from occurring.
C. Providing analgesia for headaches addresses a symptom of autonomic dysreflexia but does not prevent it.
D. Monitoring for elevated blood pressure is important in detecting autonomic dysreflexia once it has started, but it does not prevent it.