Page 2051 - Saunders Comprehensive Review For NCLEX-RN

Priority Nursing Actions

Autonomic Dysreflexia in a Spinal Cord Injury Client

1. Raise the head of the bed and ask that the primary health care provider
(PHCP) be notified.
2. Loosen tight clothing on the client.
3. Check for bladder distention or other noxious stimulus.
4. Administer an antihypertensive medication.
5. Document the occurrence, treatment, and response.

Reference

Ignatavicius, Workman, Rebar (2018), p. 898.

Practice Questions

704. The nurse is assessing the motor and sensory function of an unconscious
client who sustained a head injury. The nurse should use which technique to
test the client’s peripheral response to pain?
1. Sternal rub
2. Nailbed pressure
3. Pressure on the orbital rim
4. Squeezing of the sternocleidomastoid muscle
705. The nurse is caring for the client with increased intracranial pressure as a
result of a head injury? The nurse would note which trend in vital signs if the
intracranial pressure is rising?
1. Increasing temperature, increasing pulse, increasing respirations,
decreasing blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations,
increasing blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations,
decreasing blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations,
increasing blood pressure
706. A client recovering from a head injury is participating in care. The nurse
determines that the client understands measures to prevent elevations in
intracranial pressure if the nurse observes the client doing which activity?
1. Blowing the nose
2. Isometric exercises
3. Coughing vigorously
4. Exhaling during repositioning
707. A client has clear fluid leaking from the nose following a basilar skull
fracture. Which finding would alert the nurse that cerebrospinal fluid is

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