Brandon Sharp V Sim Quizzes

Which factor(s) can trigger autonomic dysreflexia? (Select all that apply.)

Distended bladder Constipation Thermal stimulus Pressure injury

The nurse suspects that Brandon Sharp is experiencing autonomic dysreflexia; which intervention(s) would the nurse perform next to alleviate the autonomic dysreflexia, depending on the cause? (Select all that apply.)

Empty the bladder via a urinary catheter Eliminate a cold draft in the room Provide wound care for a pressure injury Insert a topical anesthetic agent in the rectum

The sudden increase in blood pressure from autonomic dysreflexia can cause which complication(s)? (Select all that apply.)

Hemorrhagic stroke Retinal hemorrhage Myocardial infarction Seizure

The nurse would hold the ordered dose of nitroglycerin and notify the physician based on which finding?

Patient report of taking avanafil 6 hours ago

The nurse has ruled out a urinary cause of autonomic dysreflexia. Which action is the priority when the nurse is assessing for bowel impaction?

Using a topical anesthetic before removing a fecal mass

The nurse recognizes the life-threatening symptoms of autonomic dysreflexia can include ( Choose Answer..) because it can cause complications such as ( Choose Answer..).

paroxysmal hypertension hemorrhagic stroke

What is the priority assessment(s) and teaching following the episode of autonomic dysreflexia? (Select all that apply.)

Monitor blood pressure every 2 to 3 minutes and other vital signs every 15 minutes until stable Provide teaching on use of nitropaste Keep bladder and bowels from becoming too full Avoid constrictive clothing Teach that an episode is possible and can occur even years after injury

Which action(s) by the nurse is the priority when a patient experiences autonomic dysreflexia? (Select all that apply.)

Raise the head of the bed to 90 degrees and lower the legs Assess for and alleviate the cause Provide antihypertensive medication

What other intervention(s) would the nurse make for Brandon Sharp to address the autonomic dysreflexia? (Select all that apply.)

Reposition the patient to high Fowler's position Remove noxious stimulus Apply nitropaste Loosen restrictive clothing

When a patient with spinal cord injury presents with autonomic dysreflexia, which sign(s) and/or symptom(s) would the nurse expect the patient to exhibit? (Select all that apply.)

Severe headache Paroxysmal hypertension Diaphoresis above the level of injury

The nurse recognizes that which clinical manifestation(s) indicate(s) autonomic dysreflexia in Brandon Sharp? (Select all that apply.)

Severe, pounding headache Profuse diaphoresis Nausea Hypertension Nasal congestion

Patients who have experienced a spinal cord injury may experience sexual dysfunction. To improve quality of life, treatments can help with sexual function. Which treatment could contraindicate giving nitroglycerin? (Select all that apply.)

Sildenafil

A patient with which condition is at the highest risk for developing autonomic dysreflexia?

Spinal cord injury above the T6 level

After initial identification of potential for autonomic dysreflexia in Brandon Sharp, the nurse's priority is to assess or assess for (Choose Answer..) followed by ( Choose Answer..).

bladder/urinary status bowel status