Nokea
When changing the position of a patient with a spinal cord injury at T4, the nurse should recognize that what symptom is an indication of an episode of autonomic dysreflexia?
- A. Nausea
- B. Pallor
- C. Goose bumps
- D. Dizziness
Correct Answer: C
Rationale: Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure injuries, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets. Other symptoms may include diaphoresis, shivering, goose bumps, flushing of the skin, and a severe pounding headache.
You may also like to solve these questions
What should the nurse do to reduce the incidence of postural hypotension in a patient with a spinal cord injury?
- A. Monitor diastolic blood pressure closely.
- B. Encourage the patient to remain in the bed.
- C. Raise the head of the bed for 15 to 20 minutes before transfer to a wheelchair.
- D. Encourage adequate intake of fluids to expand fluid volume.
Correct Answer: C
Rationale: Raising the head of the bed before transfer allows for gradual vessel accommodation from the supine position to the upright position. It is important to check the patient's blood pressure, but it will not reduce the incidence of postural hypotension. It is important to encourage the patient to get out of bed. Postural hypotension is related to a pooling of blood in the lower extremities and is not related to a fluid volume deficit.
The rehabilitation nurse can use basic rehabilitation skills regardless of the origin of the disability. What intervention would be effective for a person with arthritis, a person with a brain injury, or a person with a spinal cord injury?
- A. Encouraging large fluid intake
- B. Seeking spiritual support from a higher being
- C. Using the spouse as a support system
- D. Positioning to maintain alignment
Correct Answer: D
Rationale: Alignment preservation is an implementation that is appropriate for a variety of rehabilitation patients, regardless of the origin of their disability.
The acquisition of adaptive skills and behaviors by an individual who has been disabled since birth refers to:
- A. training.
- B. education.
- C. development.
- D. habilitation.
Correct Answer: D
Rationale: Habilitation refers to developing skills and behaviors in people who did not have the skills originally. Children who are disabled from birth have no skills to relearn and are habilitated rather than rehabilitated.
The nurse takes special care to be gentle in caring for patients with spinal cord injuries to avoid stimulating the autonomic nervous system and triggering which condition?
- A. Paresis
- B. Heterotopic ossification
- C. Postural hypotension
- D. Autonomic dysreflexia
Correct Answer: D
Rationale: Autonomic dysreflexia is a sudden and extreme elevation in blood pressure caused by a reflex action of the autonomic nervous system. It is the result of stimulation of the body below the level of the spinal cord injury.
When caring for a patient with a disability, the rehabilitation nurse provides individual treatment to help the patient stay focused on which goals?
- A. Returning to normal
- B. Independence
- C. Employment
- D. Promotion of health
Correct Answer: B
Rationale: The focus on rehabilitation is on enabling the individual to move from a totally dependent state to a level of independence.