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NUR 1025C Final SG QUESTIONS WITH CORRECT ANSWERS / 100% GUARANTEED PASS! 1. Autonomic dysreflexia happens with spinal cord injuries some causes include bladder distention, tight clothing, increased room temperature and fecal impaction. If a patient comes in and their BP is high, they have a flushed face & blurred vision one of the things you will do is check their bladder for distention. A nurse assesses a client with a spinal cord injury at level T5. The client’s blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker. ANS: C The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate. EXTRA: The nurse is caring for a patient with spinal cord injury (SCI). Which interventions does the nurse use to target and prevent a potential SCI complication of Autonomic Dysreflexia? (Select all that apply) a. Frequently perform passive ROM exercises. b. Loosen or remove any tight clothing. c. Monitor stool output and maintain a bowel program. d. Keep the patient immobilized with neck or back braces. e. Monitor urinary output and check for bladder distention. ANS: B,C,E 2. Hepatitis A, fecal contamination, food and water. After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the client's understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for additional teaching? CONTINUES....
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