Unit 4 sample questions Flashcards
What is the difference between a complete and incomplete spinal cord injury ?
A complete spinal cord injury results in a total and irreversible loss of sensory, motor, and autonomic function below the level of injury. In contrast, an incomplete injury preserves some function below the primary injury site.
Describe the clinical manifestation of central cord syndrome.
greater functional motor loss in the arms than in the legs, along with bladder dysfunction and variable loss of sensation below the level of injury.
What causes anterior cord syndrome ?
Anterior cord syndrome is usually caused by anterior compression from bony fragments or acute disk herniation
What are clinical manifestation typically observed with anterior cord syndrome ?
Clinical manifestations include loss of motor function, pain, temperature sensation, crude touch, and pressure below the injury site, with preserved proprioception and fine touch.
Explain the etiology of brown- séquard syndrome
Brown-Séquard syndrome results from a hemisection of the spinal cord, typically due to penetrating injury.
What are the clinical manifestation of brown- séquard syndrome ?
presents with ipsilateral loss of motor function, proprioception, and vibration, along with contralateral loss of pain and temperature sensation.
What level of SCI might lead to ventilator dependence due to diaphragm innervation loss?
Injuries at the C3-C4, anything above C5
What are diagnostic procedures essential for confirming a spinal cord injury ?
X-ray
Ct scan
MRI
UA
H&H/HCT
CBC
Neuro exam
What is neurogenic shock?
a temporary loss of all neurological activity below the injury level, including sensation and spinal reflexes, leading to flaccid paralysis.
What are some characteristics of neurogenic shock?
Hypotension
Bradycardia
Reduced cardiac output
Peripheral vasodilation
Temperature instability.
What are the interventions for managing autonomic dysreflexia?
Monitor blood pressure
Elevate HOB
Remove restrictive clothing
Check for bladder and bowel issues
Administer antihypertensives
What are some nursing interventions to prevent complications in patients with SCI?
Maintain suction equipment at bedside
Teach cough and deep breathing
Ensuring spinal immobilization
Perform passive ROM
Reposition regularly
Educating about skin care
What are the primary goals of rehabilitation for patients with SCI?
Minimizing muscle wasting
Prevent contractures
Relearning of ADL’s
Maximizing mobility
What are characteristics of central cord syndrome?
A) Loss of motor function below the injury level
B) Loss of sensation primarily in the legs
C) Greater functional motor loss in the arms than in the legs
D) Complete recovery of sensory and motor functions
C) Greater functional motor loss in the arms than in the legs
Which syndrome presents with preserved proprioception and fine touch but loss of motor function, pain, and temperature sensation below the injury site?
A) Central cord syndrome
B) Anterior cord syndrome
C) Posterior cord syndrome
D) Brown-Séquard syndrome
B. Anterior cord syndrome
What is a clinical manifestation of Brown-Séquard syndrome?
A) Ipsilateral loss of motor function and proprioception
B) Contralateral loss of motor function and pain sensation
C) Bilateral loss of motor and sensory functions
D) Loss of sensation only
A. Ipsilateral loss of motor function and proprioception
At what spinal cord level might a patient become ventilator dependent duet o diaphragm loss?
A. T6
B. C3-C4
C. L5
D. S1
B. C3- C4
What diagnostic test is most suitable for evaluating spinal cord injuries for bony fragments or acute disk herniation?
A. Standard X-ray
B. MRI
C. UA
D. CT scan
D. CT scan
What is key interventions for managing autonomic dysreflexia in a patient with a spinal cord injury ?
A) Administering sedatives
B) Monitoring blood pressure closely
C) Providing a warm blanket
D) Encouraging deep breathing exercises
B. Monitoring Blood pressure closely
Which nursing intervention is essential to prevent complications like skin breakdown in a spinal cord injury patients ?
A. Administering muscle relaxers
B. Providing passive range of motion exercises
C. Apply a halo traction
D. Educating about proper skin care and repositioning
D. Educating about proper skin care and repositioning
What is the primary goal of rehabilitation in spinal cord injury patients ?
A) Maximizing muscle wasting
B) Minimizing mobility
C) Preventing contractures
D) Minimizing activities of daily living (ADLs)
C) Preventing contractures
Which diagnostic imaging modality is most appropriate for visualizing acute compression of the spinal cord ?
A. Standard X-ray
B. CT scan
C. MRI
D. Ultrasound
C. MRI
What is the key nursing intervention to prevent complications related to immobility in spinal cord injury patients?
A. Administering vasopressors
B. Performing passive range of motion
C. Monitoring ECG continuously
D. Applying HALO traction
B. Performing passive range of motion
Which medication is commonly used to manage neuropathic pain in spinal cord injuries ?
A. Opioids
B. Aspirin
C. Gabapentin
D. Antibiotics
C. Gabapentin
What is the recommended nursing intervention to prevent skin breakdown in a patient with spinal cord injury who uses a wheelchair?
A) Applying ice packs to bony prominences
B) Performing passive range of motion exercises
C) Encouraging the use of pressure-relieving cushions
D) Administering muscle relaxants regularly
C) Encouraging the use of pressure-relieving cushions
During the acute phase of spinal cord injury, what nursing action takes priority to prevent respiratory complications?
A) Encouraging ambulation
B) Administering opioid analgesics
C) Teaching deep breathing and coughing exercises
D) Applying ice packs to the neck
C) Teaching deep breathing and coughing exercises
What medications is commonly used to manage spasticity in patients with spinal cord injuries?
A. Lovenox
B. Gabapentin
C. Baclofen
D. Atropine
C. Baclofen
What nursing intervention is essential when performing pin site care for a patient in halo traction?
A) Administering antihypertensive medications
B) Monitoring blood glucose levels
C) Ensuring proper alignment of the halo device
D) Checking for signs of infection and skin breakdown
D) Checking for signs of infection and skin breakdown
Which nursing action is appropriate when assessing a patient with spinal cord injury in bowel management ?
A) Administering laxatives without assessing bowel function
B) Encouraging increased fluid intake only
C) Implementing a bowel training regimen
D) Applying a heating pad to the abdomen
C) Implementing a bowel training regimen
A patient with a spinal cord injury at T6 presents with symptoms of autonomic dysreflexia. What initial nursing intervention should be prioritized?
A) Administering pain medication
B) Elevating the head of the bed
C) Checking for bladder distension
D) Performing passive range of motion exercises
B. Elevate head of bed
What is the primary rationale for implementing intermittent catheterization in a patient with a spinal cord injury affecting bladder function?
A) Preventing urinary tract infections
B) Promoting bladder distension
C) Minimizing fluid intake
D) Reducing the need for bladder training
A. Preventing urinary tract infection
When educating a patient with spinal cord injury about preventing pressure ulcers, what should the nurse emphasize regarding skin care?
A) Avoiding use of moisturizers
B) Keeping the skin dry and unwashed
C) Performing regular skin assessments
D) Using abrasive cleansing pads
C. Perform regular skin assessments
What nursing action is appropriate to manage neurogenic shock in a patient with a spinal cord injury ?
A. Administration of vasopressors to increase blood pressure
B. Elevate the legs above the heart level
C. Encouraging deep breathing exercise
D. Applying cold packs to the extremities
B.elevate the legs above the heart level
Explanation: Elevating the legs helps facilitate venous return and improve circulation in patients experiencing neurogenic shock.
Select all nursing interventions that are appropriate for managing autonomic dysreflexia in a patient with a spinal cord injury:
A) Elevating the head of the bed
B) Administering antihypertensive medications as ordered
C) Checking for bladder distention and catheterizing if needed
D) Applying cold packs to the extremities
E) Assessing for bowel impaction and providing interventions if necessary
A) Elevating the head of the bed
B) Administering antihypertensive medications as ordered
C) Checking for bladder distention and catheterizing if needed
E) Assessing for bowel impaction and providing interventions if necessary
Select all nursing actions that are essential for preventing skin breakdown in a patient with a spinal cord injury who uses a wheelchair
A. Encouraging adequate fluid intake
B) Applying pressure-relieving cushions on the wheelchair
C) Performing regular skin assessments
D) Educating the patient on proper skin care techniques
E) Administering muscle relaxants to prevent spasticity
B) Applying pressure-relieving cushions on the wheelchair
C) Performing regular skin assessments
D) Educating the patient on proper skin care techniques
Select all appropriate nursing interventions for promoting respiratory function in a patient with a cervical spinal cord injury:
A) Encouraging use of incentive spirometry
B) Performing passive range of motion exercises
C) Teaching deep breathing and coughing techniques
D) Monitoring for signs of autonomic dysreflexia
E) Administering opioid analgesics as needed
A. Encouraging use of incentive spirometer
C. Teaching deep breathing and coughing
Which of the following are clinical manifestations associated with Guillain-Barré syndrome (GBS)?
A) High fever and chills
B) Ascending flaccid paralysis
C) Joint pain and stiffness
D) Increased deep tendon reflexes
B. Ascending flaccid paralysis
Which statement accurately describes the stages of GBS?
A) The acute stage is characterized by demyelination and axonal regeneration.
B) The recovery stage is marked by onset of clinical manifestations and inflammation.
C) The plateau stage is when demyelination ceases, lasting a few days to weeks.
D) The acute stage typically lasts several months before improvement is seen.
C) The plateau stage is when demyelination ceases, lasting a few days to weeks.
Which diagnostic test result is typical in GBS?
A. Elevated white blood cell count in CSF
B. Decreased protein level in lumbar puncture
C. Slowed nerve conduction velocity on electromyography (EMG)
D. Normal deep tendon reflexes in affected limbs
C. Slowed nerve conduction velocity on electromyography (EMG)
Which intervention is a priority in the acute management of Guillain-Barré syndrome (GBS)?
A) Administering high-dose corticosteroids
B) Initiating plasmapheresis or intravenous immunoglobulin (IVIG) therapy
C) Implementing strict bed rest and immobilization
D) Administering prophylactic antibiotics to prevent infections
B) Initiating plasmapheresis or intravenous immunoglobulin (IVIG) therapy
Which nursing interventions are appropriate for managing respiratory complications in a patient with Guillain-Barré syndrome (GBS)? Select all that apply.
A) Monitor respiratory rate and effort regularly.
B) Administer corticosteroids to reduce inflammation.
C) Assess and maintain adequate airway clearance.
D) Encourage deep breathing exercises and coughing techniques.
E) Implement early mobilization and ambulation.
A) Monitor respiratory rate and effort regularly.
C) Assess and maintain adequate airway clearance.
D) Encourage deep breathing exercises and coughing techniques.
Which nursing assessments are important for monitoring neurological status in a patient with Guillain-Barré syndrome (GBS)? Select all that apply.
A) Cranial nerve assessment
B) Glasgow Coma Scale (GCS)
C) Monitoring for changes in deep tendon reflexes
D) Assessing for cognitive deficits
E) Evaluating motor strength and sensation
A. Cranial nerve assessment
C. Monitoring for changes in deep tendon reflexes
E. Evaluating motor strength and sensation
Which nursing interventions are appropriate for managing complications associated with Guillain-Barré syndrome (GBS)? Select all that apply.
A) Monitoring for signs of respiratory distress
B) Administering high-dose corticosteroids
C) Implementing VTE prevention measures
D) Performing regular skin assessments
E) Educating the patient and family about GBS stages
A) Monitoring for signs of respiratory distress
C) Implementing VTE prevention measures
D) Performing regular skin assessments
E) Educating the patient and family about GBS stages
Which of the following statements accurately describes GBS?
A) GBS is a genetic disorder affecting the central nervous system.
B) GBS is an autoimmune disorder characterized by peripheral nerve myelin destruction.
C) GBS primarily affects the brainstem and cerebellum.
D) GBS is caused by a deficiency of acetylcholine receptors at the neuromuscular junction.
B) GBS is an autoimmune disorder characterized by peripheral nerve myelin destruction.
Which clinical manifestation is commonly seen in Guillain-Barré syndrome (GBS)?
A) Hypertension and tachycardia
B) Hyperreflexia and muscle rigidity
C) Ascending paralysis starting in the lower extremities
D) Persistent fever and productive cough
C) Ascending paralysis starting in the lower extremities
Which diagnostic test is used to confirm Guillain-Barré syndrome (GBS)?
A) Magnetic resonance imaging (MRI) of the brain
B) Lumbar puncture (analysis of cerebrospinal fluid)
C) Electrocardiogram (ECG)
D) Complete blood count (CBC)
B. Lumbar puncture
A 45-year-old male presents to the emergency department with complaints of progressive weakness in his legs over the past week. He reports a recent upper respiratory tract infection about two weeks ago. On examination, the patient has decreased deep tendon reflexes and ascending paralysis. Vital signs are stable. What condition should the nurse suspect based on these findings?
A) Multiple sclerosis
B) Guillain-Barré syndrome (GBS)
C) Amyotrophic lateral sclerosis (ALS)
D) Myasthenia gravis
B. Guillain-Barré syndrome
A 30-year-old female with a known history of Guillain-Barré syndrome (GBS) is admitted to the hospital with worsening weakness and difficulty breathing. She is now exhibiting signs of respiratory distress with shallow breathing and decreased oxygen saturation. What should be the nurse’s immediate action?
A) Administer a high-dose corticosteroid
B) Prepare for plasmapheresis or intravenous immunoglobulin (IVIG) therapy
C) Initiate mechanical ventilation and monitor respiratory status closely
D) Perform a lumbar puncture to assess cerebrospinal fluid (CSF) protein levels
C. Initiate mechanical ventilation and monitor respiratory status closely
A 55-year-old male with Guillain-Barré syndrome (GBS) is being discharged from the hospital after recovering from the acute phase. What nursing education should be prioritized for the patient and family?
A) Teach the importance of maintaining strict bed rest to prevent complications.
B) Instruct on performing daily deep breathing exercises and coughing techniques.
C) Provide information on the use of corticosteroids for long-term management.
D) Discuss the need for regular lumbar punctures for disease monitoring.
B) Instruct on performing daily deep breathing exercises and coughing techniques.
a 40-year-old male, sustained a spinal cord injury at the C5 level due to a motor vehicle accident. He has impaired respiratory function and requires mechanical ventilation. Which neurological level of injury is most likely causing the need for ventilator support?
A) C1-C2
B) C3-C4
C) C6-C7
D) T10-L2
B. C3-C4
30-year-old female, sustained a spinal cord injury at the T12 level following a fall. She presents with loss of motor and sensory function in both lower extremities. What is the most likely classification of her injury?
A) Paraplegia
B) Quadriplegia
C) Hemiplegia
D) Monoplegia
A. Paraplegia
55-year-old male, experienced an anterior spinal cord syndrome following a vertebral fracture. What clinical manifestation is commonly observed in anterior cord syndrome?
A) Loss of proprioception
B) Intact pain and temperature sensation
C) Preserved motor function below the injury
D) Retained deep tendon reflexes
B. Intact pain and temperature sensation
a 25-year-old female, presents with symptoms of central cord syndrome following a fall. What characteristic clinical manifestation is typically observed in central cord syndrome?
A) Loss of fine touch and proprioception
B) Greater motor weakness in the legs than in the arms
C) Variable loss of bladder function
D) Ascending paralysis from the lower extremities
B. Greater weakness in the legs than in the arms
a 50-year-old male, sustained a penetrating injury resulting in Brown-Séquard syndrome. What neurological deficits are expected in Brown-Séquard syndrome?
A) Ipsilateral loss of motor function, proprioception, and vibration
B) Contralateral loss of pain and temperature sensation
C) Bilateral loss of fine touch and pressure
D) Complete loss of motor and sensory function below the injury level
A) Ipsilateral loss of motor function, proprioception, and vibration
60-year-old female, experienced an acute compression injury resulting in posterior cord syndrome. What sensory deficits are typically seen in posterior cord syndrome?
A) Loss of pain and temperature sensation
B) Intact proprioception and fine touch
C) Complete loss of motor function
D) Absence of deep tendon reflexes
B. Intact proprioception and fine touch
During a mass casualty incident, what is the priority action for the nurse to ensure effective triage?
A) Administering medications to stabilize critical patients
B) Quickly assessing each patient’s injuries and assigning a triage category
C) Performing detailed physical examinations on all patients
D) Contacting family members of the injured individuals
B) Quickly assessing each patient’s injuries and assigning a triage category
What is a key principle of providing nursing care during a mass casualty incident?
A) Administering specialized treatments to all patients
B) Utilizing minimal resources to conserve supplies
C) Focusing on stabilizing patients with minor injuries first
D) Collaborating with interdisciplinary teams for coordinated care
D) Collaborating with interdisciplinary teams for coordinated care
What is a priority nursing intervention for managing a mass casualty incident involving traumatic injuries?
A) Administering prophylactic antibiotics to all injured patients
B) Implementing psychological first aid to reduce emotional distress
C) Assessing and addressing airway, breathing, and circulation (ABC) needs
D) Distributing pain medications to all patients to alleviate discomfort
C) Assessing and addressing airway, breathing, and circulation (ABC) needs
What is a key component of disaster preparedness for nurses involved in mass casualty incidents?
A) Memorizing detailed treatment protocols for various injuries
B) Maintaining personal emergency supplies at all times
C) Participating in regular disaster drills and training exercises
D) Requesting additional staff for increased patient workload
C) Participating in regular disaster drills and training exercises
Which nursing intervention is most appropriate for a patient diagnosed with PTSD (Post-Traumatic Stress Disorder) experiencing hyperarousal symptoms?
A) Encourage avoidance behaviors to minimize triggers
B) Teach relaxation techniques such as deep breathing and mindfulness
C) Provide exposure therapy to desensitize the patient to traumatic memories
D) Administer benzodiazepines to reduce anxiety
B) Teach relaxation techniques such as deep breathing and mindfulness
Which medication is commonly prescribed for patients with PTSD to alleviate symptoms of anxiety and hyperarousal?
A) Selective serotonin reuptake inhibitors (SSRIs)
B) Benzodiazepines
C) Antipsychotics
D) Tricyclic antidepressants (TCAs)
A. Selective serotonin reuptake inhibitors
What is a key nursing consideration when administering medications to patients with PTSD?
A) Encourage immediate cessation of medications if side effects occur
B) Monitor for signs of medication dependence and tolerance
C) Administer medications only during acute stress episodes
D) Avoid combining medications with psychotherapy interventions
B) Monitor for signs of medication dependence and tolerance
What psychotherapeutic intervention is effective for treating PTSD by helping patients process traumatic memories?
A) Cognitive-behavioral therapy (CBT)
B) Dialectical behavior therapy (DBT)
C) Electroconvulsive therapy (ECT)
D) Group therapy sessions
A. Cognitive- behavioral therapy
Which type of shock is characterized by impaired tissue perfusion due to decreased circulating blood volume caused by fluid loss from burns, trauma, or dehydration?
A) Septic shock
B) Cardiogenic shock
C) Neurogenic shock
D) Hypovolemic shock
D. Hypovolemic shock
A 45-year-old male presents to the emergency department with profound hypotension, tachycardia, and cool, clammy skin following a severe allergic reaction. He reports difficulty breathing and swelling of his face and tongue. Which type of shock is most likely responsible for his condition?
A) Septic shock
B) Anaphylactic shock
C) Cardiogenic shock
D) Neurogenic shock
B. Anaphylactic shock
A 55-year-old female with a history of diabetes mellitus and recent urinary tract infection presents to the emergency department with fever, hypotension, and altered mental status. Her initial vital signs are: blood pressure 80/50 mmHg, heart rate 120 bpm, respiratory rate 24/min, and temperature 39°C (102.2°F). Which of the following assessments is most indicative of septic shock in this patient?
A) Bradycardia
B) Hyperthermia
C) Hypertension
D) Hypoglycemia
B. Hyperthermia
The nurse is caring for a patient diagnosed with septic shock. Which of the following interventions is the priority in the management of this patient?
A) Administering a beta-blocker
B) Initiating strict fluid restriction
C) Providing broad-spectrum antibiotics
D) Applying a heating pad to reduce fever
C) Providing broad-spectrum antibiotics
Which of the following laboratory findings is characteristic of septic shock?
A) Decreased platelet count
B) Decreased serum lactate levels
C) Elevated white blood cell count
D) Elevated procalcitonin levels
D) Elevated procalcitonin levels
The nurse is assessing a patient with septic shock. Which hemodynamic parameter is typically observed in this condition?
A) Increased systemic vascular resistance (SVR)
B) Decreased cardiac output (CO)
C) Decreased central venous pressure (CVP)
D) Increased pulmonary artery wedge pressure (PAWP)
B) Decreased cardiac output (CO)
Which of the following complications is associated with septic shock?
A) Hypoventilation
B) Acute kidney injury (AKI)
C) Hyperglycemia
D) Bradycardia
B. AKI
Which of the following clinical manifestations is characteristic of the early stage of septic shock?
A) Hypotension
B) Hyperthermia
C) Tachypnea
D) Increased urine output
C) Tachypnea
Which of the following laboratory findings is commonly observed in the late stage of septic shock?
A) Elevated white blood cell count
B) Decreased serum lactate levels
C) Elevated creatinine levels
D) Normal procalcitonin levels
C. Elevated creatinine levels
During a mass casualty incident, which color code designation indicates the highest priority for immediate medical attention?
A) Green
B) Yellow
C) Red
D) Black
C. Red
What does the color black typically signify in the triage system during mass casualties?
A) Minimal injuries requiring basic care
B) Deceased or expectant patients
C) Severe injuries requiring immediate attention
D) Non-urgent injuries
B. Decreased or expectant patients
A patient presents to the emergency department with sudden onset dyspnea, tachypnea, and chest pain. Upon assessment, you note absent breath sounds on the affected side, tracheal deviation away from the affected side, and hypotension. Which of the following conditions is most likely present?
A) Pulmonary embolism
B) Acute respiratory distress syndrome (ARDS)
C) Tension pneumothorax
D) Myocardial infarction
C) Tension pneumothorax
Which intervention is a priority in the management of a patient suspected of having tension pneumothorax?
A) Administering oxygen therapy
B) Administering intravenous antibiotics
C) Initiating positive pressure ventilation
D) Performing needle decompression
D) Performing needle decompression
Which of the following signs and symptoms is characteristic of tension pneumothorax?
A) Cough with pink-tinged sputum
B) Unequal chest expansion
C) Bradycardia
D) Normal breath sounds on auscultation
B) Unequal chest expansion
B. The nurse at the clients head controls the turn
E. The client remains in alignment while turning
A. Heavy sweating
C. Pallor below the level of injury
E. Severe headache
D. Muscle relaxants
A. Prevention of further damage to the spinal cord
B. A client with syncope, and shortness of breath who has a heart rate of 180/min
A. Contractures of the extremities
D. Crackles in the lungs
E. Pressure ulcers
A. A young adult client who has Crohn’s disease and is scheduled for an ileostomy in 24 hrs
B. Immediate
C
A
B
E
D
A. A client with an open fracture on the left tibia and fibula
A. Bathe a client who had an amputation 2 days ago
B. Assist a client to ambulate using a gait belt
E. Measure and document a clients intake and output
C. Reinforce teaching to a client about taking enoxaparin at home following a hip arthroplasty
Which of the following types of shock is characterized by widespread infection and systemic inflammatory response syndrome (SIRS)?
A) Neurogenic shock
B) Spinal shock
C) Septic shock
D) Cardiogenic shock
B. Septic shock
Which type of shock is caused by a sudden loss of blood volume leading to inadequate tissue perfusion?
A) Neurogenic shock
B) Spinal shock
C) Hypovolemic shock
D) Cardiogenic shock
C. Hypovolemic shock
patient presents with hypotension, bradycardia, and warm/dry skin following a spinal cord injury. Which type of shock is most likely occurring?
A) Neurogenic shock
B) Septic shock
C) Cardiogenic shock
D) Hypovolemic shock
A. Neurogenic shock
What type of shock is associated with impaired heart function leading to inadequate tissue perfusion?
A) Septic shock
B) Neurogenic shock
C) Cardiogenic shock
D) Hypovolemic shock
C. Cardiogenic shock
A patient with severe burns over a large percentage of their body is most at risk of developing which type of shock?
A) Neurogenic shock
B) Septic shock
C) Cardiogenic shock
D) Hypovolemic shock
D. Hypovolemic shock
In which type of shock does the body experience a sudden loss of sympathetic tone leading to vasodilation and pooling of blood in the peripheral vessels?
A) Neurogenic shock
B) Septic shock
C) Cardiogenic shock
D) Hypovolemic shock
A. Neurogenic shock
Autonomic dysreflexia is a potentially life-threatening condition that most commonly occurs in patients with:
A) Hypoglycemia
B) Spinal cord injury at or above T6
C) Chronic obstructive pulmonary disease (COPD)
D) Congestive heart failure
B) Spinal cord injury at or above T6
Which of the following is NOT a typical symptom of autonomic dysreflexia?
A) Severe headache
B) Hypertension
C) Bradycardia
D) Diaphoresis (sweating)
Answer: C) Bradycardia
The most common trigger for autonomic dysreflexia in spinal cord injury patients is:
A) Exercise
B) Emotional stress
C) Bowel or bladder distention
D) Exposure to cold temperatures
C) Bowel or bladder distention
During an episode of autonomic dysreflexia, the nurse should first:
A) Administer intravenous fluids
B) Lower the patient’s legs
C) Remove any triggering stimuli
D) Check the patient’s blood glucose
C. Remove any triggering stimuli
Which of the following interventions is appropriate for managing autonomic dysreflexia?
A) Apply cold compresses to the forehead
B) Position the patient in a sitting position with legs elevated
C) Administer a vasodilator medication
D) Catheterize to relieve urinary retention
D) Catheterize to relieve urinary retention
Which medication is commonly used to manage acute episodes of autonomic dysreflexia?
A) Nitroglycerin
B) Furosemide
C) Nifedipine
D) Atropine
C) Nifedipine
