Autonomic Dysreflexia (SCI), Neuro Shock, Stroke Questions

Autonomic Dysreflexia (SCI), Neuro Shock, Stroke Questions 4.0 (1 review) Students also studied Terms in this set (45) Science MedicineNursing Save NCLEX Review - Management of Ca...26 terms ish_jayme_penafiel Preview Spinal Cord Injury NCLEX Questions...Teacher 53 terms julia11213Preview Autonomic Dysreflexia Questions 11 terms Aaliyahmamia22 Preview Nclex Q 32 terms kar Which patient below is at MOST risk for developing a condition called autonomic dysreflexia?

• A 24-year-old male patient with a traumatic brain

injury.

• A 15-year-old female patient with a spinal cord injury at

C7.

• A 35-year-old male patient with a spinal cord injury at

L6.

• A 42-year-old male patient recovering from a

hemorrhagic stroke.

• Patients who are at MOST risk for developing autonomic dysreflexia are patients

who've experienced a spinal cord injury at T6 or higher...this includes C7. L6 is below T6, and traumatic brain injury and hemorrhagic stroke does not increase a patient risk of AD.Your patient, who has a spinal cord injury at T3, states they are experiencing a throbbing headache. What is your NEXT nursing action?

• Perform a bladder scan
• Perform a rectal digital examination
• Assess the patient's blood pressure
• Administer a PRN medication to alleviate pain and

provide a dark, calm environment.

• This is the nurse's NEXT action. The patient is at risk for developing autonomic

dysreflexia because of their spinal cord injury at T3 (remember patients who have a SCI at T6 or higher are at MOST risk). If a patient with this type of injury states they have a headache, the nurse should NEXT assess the patient's blood pressure.If it is elevated, the nurse would take measures to check the bladder (a bladder issue is the most common cause of AD), bowel, and skin for breakdown.

You're performing a head-to-toe assessment on a patient with a spinal cord injury at T6. The patient is restless, sweaty, and extremely flushed. You assess the patient's blood pressure and heart rate. The patient's blood pressure is 140/98 and heart rate is 52. You look at the patient's chart and find that their baseline blood pressure is 106/76 and heart rate is 72. What action should the nurse take FIRST?

• Reassess the patient's blood pressure.
• Check the patient's blood glucose.
• Position the patient at 90 degrees and lower the legs.
• Provide cooling blankets for the patient.
• Based on the patient findings and how the patient has a spinal cord injury at T6,

they are experiencing autonomic dysreflexia. Patients with this condition may have a blood pressure that is 20-40 mmHg higher than their baseline and may experience bradycardia (heart rate less than 60). The FIRST action the nurse should take when AD is suspected is to position the patient at 90 degree (high Fowler's) and lower the legs. This will allow gravity to cause the blood to pool in the lower extremities and help decrease the blood pressure. Then the nurse should try to find the cause of the autonomic dysreflexia, which could be a full bladder, impacted bowel, or skin break down.You're providing an in-service to a group of new nurse graduates on the causes of autonomic dysreflexia. Select all the most common causes you will discuss during the

in-service:

• Hypoglycemia
• Distended bladder
• Sacral pressure injury
• Fecal impaction
• Urinary tract infection

B, C, D, and E. Anything that can cause an irritating stimulus below the site of the spinal injury (T6 or higher) can lead to autonomic dysreflexia, which causes an exaggerated sympathetic reflex response and the parasympathetic system is unable to oppose it. This will lead to severe hypertension. The most common cause of AD is a bladder issue (full/distended bladder, urinary tract infection etc).Other common causes are due to a bowel issue like fecal impaction or skin break down (pressure injury/ulcer, cut, infection etc.).After taking all the necessary steps for a patient who has developed autonomic dysreflexia, what should the nurse assess FIRST as a possible cause of this condition?

• Skin break down
• Blood glucose
• Possible bladder irritant
• Last bowel movement
• A bladder issue is usually the most common cause of AD. If this isn't the issue

the nurse should assess the bowel and then the skin for break down.The physician orders Nitropaste for a patient who has developed autonomic dysreflexia. Which finding would require the nurse to hold the ordered dose of Nitropaste and notify the physician?

• The patient's blood pressure is 130/80.
• The patient reports a throbbing headache.
• The patient's lower extremities are pale and cool.
• The patient states they took Sildenafil 12 hours ago.
• A patient should not receive a dose of Nitropaste if they have taken a

phosphodiesterase inhibitor within the past 24 hours (Sildenafil or Tadalafil). This will cause major vasodilation and severe hypotension that will not respond to medication. Another medication should be used. All the other findings are expected with autonomic dysreflexia.A patient is receiving treatment for a complete spinal cord injury at T4. As the nurse you know to educate the patient on the signs and symptoms of autonomic dysreflexia. What signs and symptoms will you educate

the patient about? Select all that apply:

• Headache
• Low blood glucose
• Sweating
• Flushed below site of injury
• Pale and cool above site of injury
• Hypertension
• Slow heart rate
• Stuffy nose

A, C, F, G and H. All of these are signs and symptoms of autonomic dysreflexia.The patient will have flushing above site of injury due to vasodilation from parasympathetic activity, BUT will be pale and cool below site of injury due to vasoconstriction occurring below the site of injury for the sympathetic response reflex.

What is the BEST position for a patient experiencing autonomic dysreflexia?

• High Fowler's with legs lowered
• Low Fowler's with legs lowered
• Semi-Fowler's with legs at heart level
• Prone
• The patient should be in high Fowler's (90 degrees) with the legs lowered. This

will allow gravity to cause blood to pool in the lower extremities and help decrease blood pressure.In autonomic dysreflexia, the nurse would expect what finding below the site of the spinal cord injury?

• Flushed lower body
• Pale and cool lower extremities
• Low blood pressure
• Absent reflexes
• The lower extremities would be cool and pale due to vasconstriction caused by

the exaggerated reflex response of the sympathetic nervous system from an irritating stimulus. The sympathetic reflex can NOT be unopposed by the parasympathetic nervous system due to the spinal injury, which is blocking the nerve impulse. The areas found ABOVE the site of injury would be flushed due to vasodilation from parasympathetic stimulation.Which statements are TRUE about autonomic dysreflexia?

Select all that apply:

• "Autonomic dysreflexia is an exaggerated reflex

response by the parasympathetic nervous system that results in severe hypertension due to a spinal cord injury."

• "Autonomic dysreflexia causes a slow heart rate and

severe hypertension."

• "Autonomic dysreflexia is less likely to occur in a

patient who has experienced a lumbar injury."

• "The first-line of treatment for autonomic dysreflexia is

an antihypertensive medication." B and C. Option A is false, it should say: Autonomic dysreflexia is an exaggerated reflex response by the SYMPATHETIC (NOT parasympathetic) nervous system that results in severe hypertension due to a spinal cord injury. Option B is false because medications are used only if the blood pressure is not decreasing or the cause cannot be determined.The nurse is about to assess for bowel impaction in a patient who has developed autonomic dysreflexia. The nurse makes it priority to?A. Avoid using lubricants

• Stimulate the bowel with rectal manipulation
• Slowly administer a saline solution prior to assessment
• Instill an anesthetic jelly prior to assessment
• To avoid increasing autonomic dysreflexia symptoms by increasing the

sympathetic reflex due to an irritating stimulus, the nurse should instill an anesthetic jelly before assessing the rectum for hardened stool. This is also important prior to catheterization to check the bladder for urine.You're working on a neuro unit. Which of your patients below are at risk for developing neurogenic shock?

Select all that apply:

• A 36-year-old with a spinal cord injury at L4.
• A 42-year-old who has spinal anesthesia.
• A 25-year-old with a spinal cord injury above T6.
• A 55-year-old patient who is reporting seeing green

halos while taking Digoxin.B and C. Any patient who has had a cervical or upper thoracic (above T6) spinal cord injury, receiving spinal anesthesia, or taking drugs that affect the autonomic or sympathetic nervous system is at risk for developing neurogenic shock.

True or False: The parasympathetic nervous system loses

the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes.

FALSE....the statement should say: The sympathetic (NOT parasympathetic)

nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes.

A 42-year-old male patient is admitted with a spinal cord injury. The patient is experiencing severe hypotension and bradycardia. The patient is diagnosed with neurogenic shock. Why is hypotension occurring in this patient with neurogenic shock?

• The patient has an increased systemic vascular

resistance. This increases preload and decreases afterload, which will cause severe hypotension.

• The patient's autonomic nervous system has lost the

ability to regulate the diameter of the blood vessels and vasodilation is occurring.

• The patient's parasympathetic nervous system is being

unopposed by the sympathetic nervous system, which leads to severe hypotension.

• The increase in capillary permeability has depleted the

fluid volume in the intravascular system, which has led to severe hypotension.

• The sympathetic nervous system (which is a division of the autonomic nervous

system) is unable to stimulate the nerves that regulate the diameter of the blood vessels (there's a loss of vasomotor tone). So, now the vessels are relaxed and this causes massive vasodilation. Systemic vascular resistance will decrease and hypotension will occur.You receive a patient in the ER who has sustained a cervical spinal cord injury. You know this patient is at risk for neurogenic shock. What hallmark signs and symptoms, if experienced by this patient, would indicate the patient is experiencing neurogenic shock? Select all

that apply:

• Blood pressure 69/38
• Heart rate 170 bpm
• Blood pressure 250/120
• Heart rate 29
• Warm and dry extremities
• Cool and clammy extremities
• Temperature 104.9 'F
• Temperature 95 'F

A, D, E, and H. Hallmark signs and symptoms of neurogenic shock are:

hypotension, bradycardia, hypothermia, warm/dry extremities (this is due to the vasodilation and blood pooling and will be found in the extremities).In neurogenic shock, a patient will experience a decrease in tissue perfusion. This deprives the cells of oxygen that make up the tissues and organs. Select all the mechanisms, in regards to pathophysiology, of why this is

occurring:

• Loss of vasomotor tone
• Increase systemic vascular resistance
• Decrease in cardiac preload
• Increase in cardiac afterload
• Decrease in venous blood return to the heart
• Venous blood pooling in the extremities

A, C, E, and F. Massive vasodilation is occurring in the body and this is due to the loss of vasomotor tone (remember the sympathetic nervous system loses its ability to stimulate nerves that regular the diameter of vessels....so vessels are relaxed). This will DECREASE (NOT increase) systemic vascular resistance (which will decrease cardiac afterload) and the blood pressure will fall. Furthermore, there is pooling of venous blood in the extremities because there isn't any pressure to push it back to the heart. This will cause a decrease in venous blood return to the heart. When this occurs it will decrease cardiac preload (the amount the ventricle stretch at the end of diastole). All of this together will decrease the amount of blood the heart can pump per minute....hence the cardiac output and shock will occur.You're providing care to a patient experiencing neurogenic shock due to an injury at T4. As the nurse, you know which of the following is a patient safety priority?

• Keeping the head of the bed greater than 45 degrees

at all times.

• Repositioning the patient every thirty minutes.
• Keeping the patient's spine immobilized.
• Avoiding log-rolling the patient during transport.
• It is very important when a patient has a spinal cord injury to keep the spine

protected. The nurse wants to prevent further damage or perfusion issues to the spinal cord. Therefore, the patient's spine should be immobilized. Example: usage of cervical collar, log-rolling, usage of a backboard.