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Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 24-5Question 17Type: MCMAA patient with a T5 spinal cord injury has manifestations of autonomic dysreflexia. Which assessments would indicate a possible cause for this condition?Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. Presence of a pressure ulcer2. Kinked urinary catheter tubing3. Respiratory congestion4. Diarrhea5. Fecal impactionCorrect Answer: 1,2,5Rationale 1: The presence of noxious stimuli below the level of the SCI may result in autonomic dysreflexia. A pressure ulcer may cause this complication.Rationale 2: Autonomic dysreflexia can be caused by kinked catheter tubing, which allows the bladder to become full and triggers massive vasoconstriction below the injury site, producing the manifestations of this process.Rationale 3: The presence of noxious stimuli below the level of the injury triggers autonomic dysreflexia. Respiratory congestion is not likely to be the cause in this patient.Rationale 4: Diarrhea is not a common trigger for this complication.Rationale 5: Fecal impaction may provide the noxious stimulus that triggers autonomic dysreflexia.Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 24-5Question 18Type: MCSA
The nurse is providing community education regarding spinal cord injuries to a group of young adults. Which information should the nurse include?1Global Rationale: Cognitive Level: ApplyingClient Need: Health Promotion and MaintenanceClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 24-1