NCSBN PRACTICE QUESTIONS TEST BANK #2 ACCURATELY UPDATED!!

A client with a spinal cord injury at the T-2 level reports having a "pounding" headache. Further assessment by the nurse reveals excessive sweating, rash, piloerection, facial flushing, congested nasal passages and a heart rate of 50 bpm. What is the priority action? - ANSWERCheck the client for bladder distention or kinking of the urinary catheter. The client is exhibiting manifestations of autonomic dysreflexia, also called hyperreflexia, seen with a spinal cord injury (SCI), typically above the T6 level. It is most often caused by a noxious stimulus below the level of the injury such as a full bladder, an enema or bowel movement, fecal impaction, changing of an indwelling catheter and a vaginal or rectal examination. The stimulus creates an exaggerated response of the sympathetic nervous system that can be a life-threatening event. Therefore, the priority action is to identify and relieve the cause of the response. The nurse is assessing a 4-year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and appears to be having severe pain. The foot on the affected extremity is pale, cool to touch and the pulse is barely palpable. What action should the nurse take? - ANSWERNotify the primary health care provider. The pain and absence of a pulse suggests compartment syndrome. This condition occurs when there is a buildup of pressure within the muscles. This pressure decreases blood flow and can cause muscle, tissue, and nerve damage. Compartment syndrome