NCLEX-PN

Category - Reduction of Risk

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A nurse is caring for a client who sustained an injury to the spinal cord and who is at risk for autonomic dysreflexia. The nurse expects the inclusion of the following interventions in the care plan except:

Limiting the client’s fluid intake
Assisting the client in high-Fowler’s position
Keeping the client’s linen free from wrinkles
Straight catheterization every 4 hours

Explanation

Answer: A - A distended bladder, wrinkled linens, and fecal impaction can stimulate autonomic dysreflexia. The nurse should increase the client’s fluid intake to prevent constipation and fecal impaction. The other options are appropriate.

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