1. A client with gout experiences an acute attack. The client reports he has been trying to lose weight. Which client information is most important for the nurse to obtain?
• Serum cholesterol level (not related to the acute attack gout)
• Capillary glucose level (not related to the acute attack gout)
• Daily caloric intake (Starvation diet can cause an acute attack of gout)
• Daily calcium intake (not related to the acute attack gout)
2. A male client with a C-6 spinal cord injury is in rehabilitation. In the middle of the night he reports a severe, pounding headache, and has observable goose bumps. The nurse should assess for which trigger?
• Loud hallway noise (Not manifestation of autonomic hyperreflexia)
• Fever (Not manifestation of autonomic hyperreflexia)
• Full bladder
• Frequent cough (Not manifestation of autonomic hyperreflexia)
* A pounding headache is a sign of autonomic hyperreflexia, an acute emergency that occurs because of an exaggerated sympathetic response in a client with a high-level spinal cord injury. Any stimulus below the level of injury can trigger autonomic hyperreflexia, but the most common cause is an overly distended bladder.
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