The nurse is planning care for a client admitted with a high thoracic spinal cord injury. Which interventions would be appropriate for the nursing diagnosis of Ineffective Peripheral Tissue Perfusion? Select all that apply.
A)Discuss future care needs when the client is discharged.
B)Increase fluids to 3000 mL per day.
C)Turn and reposition the client every 2 hours.
D)Assess for a full bladder.
E)Assess blood pressure every 2-3 minutes.

Question

Quizplus · Accepted Answer

A)Ineffective perfusion can be caused by autonomic dysreflexia, which is an emergency that requires immediate assessment and intervention. The nurse should continue to assess the client's blood pressure every 2-3 minutes in addition to elevating the head of the bed and removing tight clothing to encourage the pooling of blood in the extremities and decrease the blood pressure. Once the client's blood pressure has stabilized or decreased, the nurse can then assess for the stimuli that caused the episode, such as a full bladder. Discussing future care needs when discharged is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion. Turning the client every 2 hours is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion.
B)Ineffective perfusion can be caused by autonomic dysreflexia, which is an emergency that requires immediate assessment and intervention. The nurse should continue to assess the client's blood pressure every 2-3 minutes in addition to elevating the head of the bed and removing tight clothing to encourage the pooling of blood in the extremities and decrease the blood pressure. Once the client's blood pressure has stabilized or decreased, the nurse can then assess for the stimuli that caused the episode, such as a full bladder. Discussing future care needs when discharged is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion. Turning the client every 2 hours is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion.
C)Ineffective perfusion can be caused by autonomic dysreflexia, which is an emergency that requires immediate assessment and intervention. The nurse should continue to assess the client's blood pressure every 2-3 minutes in addition to elevating the head of the bed and removing tight clothing to encourage the pooling of blood in the extremities and decrease the blood pressure. Once the client's blood pressure has stabilized or decreased, the nurse can then assess for the stimuli that caused the episode, such as a full bladder. Discussing future care needs when discharged is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion. Turning the client every 2 hours is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion.
D)Ineffective perfusion can be caused by autonomic dysreflexia, which is an emergency that requires immediate assessment and intervention. The nurse should continue to assess the client's blood pressure every 2-3 minutes in addition to elevating the head of the bed and removing tight clothing to encourage the pooling of blood in the extremities and decrease the blood pressure. Once the client's blood pressure has stabilized or decreased, the nurse can then assess for the stimuli that caused the episode, such as a full bladder. Discussing future care needs when discharged is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion. Turning the client every 2 hours is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion.
E)Ineffective perfusion can be caused by autonomic dysreflexia, which is an emergency that requires immediate assessment and intervention. The nurse should continue to assess the client's blood pressure every 2-3 minutes in addition to elevating the head of the bed and removing tight clothing to encourage the pooling of blood in the extremities and decrease the blood pressure. Once the client's blood pressure has stabilized or decreased, the nurse can then assess for the stimuli that caused the episode, such as a full bladder. Discussing future care needs when discharged is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion. Turning the client every 2 hours is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion.

The Nurse Is Planning Care for a Client Admitted with a High