Nokea
A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?
- A. Respiratory distress and projectile vomiting
- B. Bradycardia and hypertension
- C. Tachycardia and agitation
- D. Third-spacing and hyperthermia
Correct Answer: B
Rationale: Autonomic dysreflexia presents with bradycardia, hypertension, headache, sweating, and nasal congestion due to sympathetic stimulation above T6. Other symptoms listed are not characteristic.
You may also like to solve these questions
Paramedics have brought an intubated patient to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?
- A. Keep the head of the bed (HOB) flat at all times.
- B. Teach the patient to perform the Valsalva maneuver.
- C. Administer benzodiazepines on a PRN basis.
- D. Perform endotracheal suctioning every hour.
Correct Answer: C
Rationale: Benzodiazepines control agitation without raising ICP. HOB should be elevated, Valsalva and frequent suctioning increase ICP.
A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure?
- A. MRI
- B. PET scan
- C. X-ray
- D. Ultrasound
Correct Answer: A
Rationale: MRI is the primary tool for evaluating brain structure in diffuse axonal injury. PET scans assess function, while X-rays and ultrasound are inadequate for brain imaging.
A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patients risk for orthostatic hypotension?
- A. Administer an IV bolus of normal saline prior to repositioning.
- B. Maintain bed rest until normal BP regulation returns.
- C. Monitor the patients BP before and during position changes.
- D. Allow the patient to initiate repositioning.
Correct Answer: C
Rationale: Monitoring BP during position changes helps manage orthostatic hypotension. Boluses are impractical, bed rest carries risks, and patient-initiated changes may not prevent hypotension.
The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform?
- A. Ensure that the player is not moved.
- B. Obtain the players vital signs, if possible.
- C. Perform a rapid assessment of the players range of motion.
- D. Assess the players reflexes.
Correct Answer: A
Rationale: Immobilizing the patient prevents worsening of a potential SCI. Assessing vitals, ROM, or reflexes risks further injury.
A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patients status?
- A. Reflex activity
- B. Level of consciousness
- C. Cognitive ability
- D. Sensory involvement
Correct Answer: B
Rationale: The GCS assesses level of consciousness through eye, verbal, and motor responses. It does not evaluate reflexes, cognition, or sensory function.