NCLEX-PN
NCLEX Questions on Neurological Disorders Quizlet Questions
Extract:
Question 1 of 5
The nurse’s client with a T2 SCI is dysreflexic and has a BP of 170/90 mm Hg. Place the nurse’s interventions in the order that these should be performed.
Order the Items
Source Container
Correct Answer: C,A,B,G,F,E,D
Rationale: Elevate the HOB to 90 degrees. This initial quick action may help lower the client’s BP. Lower the end of the bed so feet are dependent. Placing the feet lower than the head will help decrease blood return and may help lower the BP. Remove elastic stocking and other constricting devices; assess below the level of injury. Anything constricting below the level of injury can be the stimulus that precipitates autonomic dysreflexia. The nurse can assess for other precipitating factors, such as a full bladder, while removing constricting devices. Retake the BP after being upright for 2 to 3 minutes. Elevating the HOB, lowering the feet, and removing constricting devices may have lowered the BP. If not, further interventions are needed. Administer a pm prescribed sublingual nifedipine for continued elevated BP. If the BP remains elevated, the prescribed antihypertensive medication, such as nifedipine (Procardia), should be given next to quickly lower the BP. Perform digital removal of impacted stool (last BM found to be 10 days ago). Digitally removing stool impaction may cause a further spike in BP, so that should be completed after the BP medication is administered. Inform the HCP of the incident, measures taken, and client response. This is last because a pro antihypertensive medication had already been prescribed. Care of the client is priority.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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