{"id":138407,"date":"2024-09-14T14:35:02","date_gmt":"2024-09-14T14:35:02","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=138407"},"modified":"2024-09-14T14:35:05","modified_gmt":"2024-09-14T14:35:05","slug":"following-morning-care","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2024\/09\/14\/following-morning-care\/","title":{"rendered":"Following morning care"},"content":{"rendered":"\n<p>Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?<\/p>\n\n\n\n<p>A.<br>Administer a prescribed PRN dose of hydralazine.<\/p>\n\n\n\n<p>B.<br>Assess the client&#8217;s blood pressures every 15 minutes.<\/p>\n\n\n\n<p>C.<br>Teach the client to recognize the symptoms of dysreflexia.<\/p>\n\n\n\n<p>D.<br>Relieve any kinks or obstruction in the client&#8217;s Foley tubing.<\/p>\n\n\n\n<p><mark style=\"background-color:rgba(0, 0, 0, 0)\" class=\"has-inline-color has-ast-global-color-6-color\"><strong>The correct answer and Explanation is :<\/strong><\/mark><\/p>\n\n\n\n<p>The correct answer is <strong>D. Relieve any kinks or obstruction in the client&#8217;s Foley tubing.<\/strong><\/p>\n\n\n\n<p>A client with a C-5 spinal cord injury is at high risk for <strong>autonomic dysreflexia (AD)<\/strong>, a potentially life-threatening condition. AD occurs in clients with spinal cord injuries at or above the T6 level. It is a result of a noxious stimulus (commonly bladder distension or bowel impaction) that the body can&#8217;t properly regulate due to the spinal cord injury. This causes an uncontrolled sympathetic response, leading to symptoms like severe hypertension, headache, flushing, sweating, and bradycardia.<\/p>\n\n\n\n<p>When a client with a C-5 spinal cord injury experiences a flushed appearance and complains of a headache, it is crucial to immediately think of AD. This is a medical emergency because it can quickly lead to complications such as stroke, seizures, or even death if not promptly addressed.<\/p>\n\n\n\n<p>The first intervention is to eliminate the source of the noxious stimulus. A common cause is bladder distension due to a kinked or obstructed urinary catheter. By relieving any kinks or obstructions in the Foley catheter, the stimulus is removed, which can help resolve the dysreflexic episode.<\/p>\n\n\n\n<p>The other options are not appropriate as first interventions:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>A (administering hydralazine)<\/strong>: While hydralazine may be prescribed to lower blood pressure, it should not be the first action, as it treats the symptom (hypertension) but not the underlying cause.<\/li>\n\n\n\n<li><strong>B (assessing blood pressure every 15 minutes)<\/strong>: Monitoring blood pressure is essential but should be done after addressing the possible causes.<\/li>\n\n\n\n<li><strong>C (teaching the client)<\/strong>: Education is important for future prevention but not the immediate priority in an acute dysreflexic episode.<\/li>\n<\/ul>\n\n\n\n<p>In summary, relieving any obstruction in the Foley catheter (D) directly addresses a common trigger of AD, making it the priority intervention in this scenario.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst? A.Administer a prescribed PRN dose of hydralazine. B.Assess the client&#8217;s blood pressures every 15 minutes. C.Teach the client to recognize the symptoms of dysreflexia. D.Relieve [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-138407","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/138407","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=138407"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/138407\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=138407"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=138407"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=138407"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}