ATI n222 Mental Health Quiz

Extract:

Question 1 of 5

A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

A. Hypotension and venous pooling in the extremities. B. Pain and a burning sensation upon urination and hematuria. C. Profuse diaphoresis and severe,pounding headache. D. Reports of chest pain and shortness of breath.

Correct Answer: C

Rationale: The correct answer is C: Profuse diaphoresis and severe, pounding headache. Autonomic dysreflexia is a life-threatening condition that occurs in clients with spinal cord injuries above T6. In this case, the C-5 spinal cord injury is above T6, making the client at risk for autonomic dysreflexia. The condition is caused by a stimulus below the level of the injury, such as a full bladder, leading to a sympathetic response. Profuse diaphoresis and severe, pounding headache are classic signs of autonomic dysreflexia due to the sympathetic response causing vasoconstriction below the level of the injury. Hypotension and venous pooling (
Choice
A) are not typical in autonomic dysreflexia. Pain and burning upon urination and hematuria (
Choice
B) are more indicative of a urinary tract infection. Reports of chest pain and shortness of breath (
Choice
D) are not typically associated with autonomic dys

Question 2 of 5

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Question 5 of 5

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ATI n222 Mental Health Quiz | Nurselytic

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