Autonomic dysreflexia question

[oztizz184]

in kaplan question trainer 7, there is a question about this.

patient has pounding headache and profuse sweating, what should the nurse do first

options: elevate HOB

options: check catheter

i chose elevate hob but the answer is check catheter

but a book and study guide said to elevate but kaplan said to check catheter

which is right for nclex?

[Double-Helix, BSN, RN]

I just had a similar question on the qbanks, and the answer was the reverse...place pt in sitting position. Did the question specify that the patient had an indwelling cath? Or did it just say pt had a SCI and had x symptoms?

Question from my qbank: This patient presents with a pounding HA, diaphoretic, etc...which is suggestive of severe RAPID hypertension...it makes sense to elevate HOB because you want to decrease the blood pressure and ICP immediately...since there is a possibility of cerebral hemorrhage and SEIZURES. After elevating the HOB, immediately empty the bladder.

So my other answer choices besides HOB, were "have the patient empty the bladder", or "Examine the rectum"...in my case, having the patient emptying the bladder and examining the rectum would take longer than elevating HOB...in your case, checking for a kink in catheter is quicker than elevating HOB.

Kaplan tends to be very very tricky with wording...and some of their rationales don't make sense, lol.

The difference between this question and the OP's is that this one doesn't mention autonomic dysreflexia, nor does it suggest that the patient has a previous neurological injury (such as paralysis) that might make them susceptible to autonomic dysreflexia.

In the OP's question, the wording clearly mentions that you're dealing with an autonomic dysreflexia response. Therefore you would choose the best answer that is most likely to correct the patient's most serious problem. In this case, bladder distention due to a kinked or clamped catheter is the most likely cause. (Yes, you assume the patient has a catheter, since the option is to check the catheter.)

In your question, there is no hint or mention of autonomic dysreflexia. Patients with neurological injuries who are susceptible to autonomic dysreflexia cannot simply empty their bladder on their own. The problem is that their body recognizes bladder distention as noxious stimuli, but cannot interpret that stimuli and the damaged nerves do not allow the patient to eliminate it. If this question were truly an autonomic dysreflexia situation, you could not "have the patient empty the bladder" as they would be unable to voluntarily do so without the assistance of a catheter.

Since you have no reason to suspect a previous neurological injury, or autonomic dysreflexia, based on the information provided in the question, the correct answer would be to choose the best answer that most likely reduces the risk of complications from the patient's presenting symptoms. In this case, it would be raising the HOB to reduce cerebral blood pressure.

The trick is in the wording, and these questions are good examples of what not to do with NCLEX questions: Don't assume information that isn't there. So if the question doesn't mention autonomic dysreflexia, paralysis, or neurological injury, don't assume any of the above is present just because they patient's symptoms would be consistent with that diagnosis.

[carygt3]

The difference between this question and the OP's is that this one doesn't mention autonomic dysreflexia, nor does it suggest that the patient has a previous neurological injury (such as paralysis) that might make them susceptible to autonomic dysreflexia.

In the OP's question, the wording clearly mentions that you're dealing with an autonomic dysreflexia response. Therefore you would choose the best answer that is most likely to correct the patient's most serious problem. In this case, bladder distention due to a kinked or clamped catheter is the most likely cause. (Yes, you assume the patient has a catheter, since the option is to check the catheter.)

In your question, there is no hint or mention of autonomic dysreflexia. Patients with neurological injuries who are susceptible to autonomic dysreflexia cannot simply empty their bladder on their own. The problem is that their body recognizes bladder distention as noxious stimuli, but cannot interpret that stimuli and the damaged nerves do not allow the patient to eliminate it. If this question were truly an autonomic dysreflexia situation, you could not "have the patient empty the bladder" as they would be unable to voluntarily do so without the assistance of a catheter.

Since you have no reason to suspect a previous neurological injury, or autonomic dysreflexia, based on the information provided in the question, the correct answer would be to choose the best answer that most likely reduces the risk of complications from the patient's presenting symptoms. In this case, it would be raising the HOB to reduce cerebral blood pressure.

The trick is in the wording, and these questions are good examples of what not to do with NCLEX questions: Don't assume information that isn't there. So if the question doesn't mention autonomic dysreflexia, paralysis, or neurological injury, don't assume any of the above is present just because they patient's symptoms would be consistent with that diagnosis.

Sorry, I didn't post the question word for word..but it does deal with Autonomic dysreflexia..Here is the idea of the question

There is patient who sustained a T5 spinal cord injury weeks ago. The nurse observes that the patient is diaphoretic, nauseated, and complaining of a severe headache. Which of the following actions should the nurse take FIRST?

A) Place the patient in a sitting position

B) Have the patient empty his bladder

C) Examine the rectum

D) Administer Apresoline as ordered

question paraphrased TOS copyright.

[oztizz184]

Thanks for all the help everyone!

Maybe I should of also included the whole question and rationales

Here it is and I'll add it to my original post:

The patient is 3 days post spinal cord injury at the level of T-5. The patient complains of a pounding headache, and the nurse notes profuse sweating on the patient’s forehead. Which of the following actions, if taken by the nurse, is BEST?

1. Determine the patency of the Foley catheter.

2. Place ice packs on the neck and head.

3. Elevate the head of the bed.

4. Apply a rigid cervical collar.

.Just kidding, can't edit original post. so its here!

question paraphrased/copyright

[oztizz184]

ahh carygt3 and my question are total opposites, I'd be totally confused on the test if this came up!!!

so check foley is #1 priority?

[carygt3]

I'm thinking...if they have a catheter it's quicker to assess than putting up the bed...so check for kinks first. If option does not give catheter option like mines..and says have pt empty bladder, or straight cath pt to alleviate...etc ...elevate HOB instead because it's quicker.

Maybe my question probably doesn't have a indwelling cath option because it has been 4 weeks since pt sustained injury..and are probably having pt train his bladder or something

Your question has an indwelling cath maybe because patient just sustained injury 3 days ago..

[oztizz184]

So true, now I get it. :)

depends on the options/answers given heh

THANKS EVERYONE!

[nurseprnRN, BSN, RN]

the other reason you would not choose "administer apresoline as ordered" is because that is part of a medical plan of care, and the nclex wants to know what you as a nurse would assess and do. yes, nurses give medications that are part of the medical plan of care, we are legally obligated to do that (if they are safe), but nclex wants to know if you know nursing assessment and intervention.

[Esme12, ASN, BSN, RN]

ahh carygt3 and my question are total opposites, I'd be totally confused on the test if this came up!!!

so check foley is #1 priority?

In the one question it says to check foley the other is to empty the bladder.....In each scenario Which would be the quickest most efficient means to correct the situation.

Check the foley tube or put the head up? the other senario........ get them out of bed to void or put the head up? Which is most likely to get results the quickest.

One is check the foley and the other is to put the head up....LOOK at the question and your options.

[Rlazarin]

Emergency Care of the Patient Experiencing Autonomic Dysreflexia: Immediate Interventions

• Place patient in sitting position (first priority!), or return to previous safe position.

• Page/notify care provider.

• Assess for and treat the cause:

• Check for urinary retention or catheter blockage:

• Check the urinary catheter tubing (if present) for kinks or obstruction.

• If a urinary catheter is not present, check for bladder distention and catheterize immediately if indicated

Medical-Surgical Nursing: Patient-Centered Collaborative Care, 8th edition, Donna Ignatavicius, M. Linda Workman, 04NOV2016 Pg. 899 Chart 43-11

[Rovs]

I googled this AD coz it says in what I'm reading now (NCLEX RN CRAM SHEET) says the first nursing intervention in a quadriplegic client who is experiencing AD is to ELEVATE HIS HEAD AS HIGH AS POSSIBLE. so I check if its really true. And yah I heard a lot says Kaplan is not really a good material for reviewing, they got wrong rationales according to others.

[nurseteam16]

Elevate the head of bed to prevent hypertensive stroke. This is what I learned so far from the book I just purchased Simple, Fast and Easy NCLEX Review by Matus Nursing Review, and it really emphasizes that preventing stroke is the first goal.