Autonomic Dysreflexia: Signs, Triggers and Nursing Actions
Autonomic dysreflexia explained in question-and-answer form: 88 original questions on recognition, triggers and the first nursing actions, each answered from and quoted from the StatPearls Autonomic Dysreflexia chapter on the National Library of Medicine's NCBI Bookshelf. For study, not for bedside decisions.
Autonomic dysreflexia nursing questions: who is at risk after spinal cord injury, the blood pressure thresholds, signs above and below the injury, bladder and bowel triggers, the first nursing steps, nitroglycerin paste and nifedipine, monitoring, prevention and patient teaching, cited to the StatPearls chapter on NCBI Bookshelf (National Library of Medicine). Every answer is grounded in a quoted source line.
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01Autonomic dysreflexia typically follows a spinal cord injury at which level? A. Below T10 only. B. At or above T6. C. At L1 to L2 only. D. Only at the sacral level.
B. At or above T6. The condition emerges after a spinal cord injury at or above T6, above the splanchnic sympathetic outflow.
VERIFIED AGAINST THE SOURCE
“Autonomic dysreflexia is a condition that emerges soon after a spinal cord injury at or above the T6 level.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗02Which trigger causes most episodes of autonomic dysreflexia? A. Bladder distention. B. Ingrown toenail. C. Sunburn. D. Tight shoelaces.
A. Bladder distention. Bladder distention accounts for about 85% of episodes and is by far the most common trigger.
VERIFIED AGAINST THE SOURCE
“Bladder distention is responsible for about 85% of all cases and is by far the most common trigger”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗03What is usually the first symptom a patient with autonomic dysreflexia reports? A. Numbness spreading up from the feet. B. A dull ache in the lower back. C. Itching of the legs. D. A sudden, severe, throbbing headache.
D. A sudden, severe, throbbing headache. The opening symptom is typically an acute, severe, throbbing headache.
VERIFIED AGAINST THE SOURCE
“The initial presenting symptom is an acute, severe headache, typically described as throbbing.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗04A patient with a T4 spinal cord injury suddenly reports a pounding headache. What should the nurse do first? A. Give acetaminophen and reassess in an hour. B. Dim the lights and let the patient sleep. C. Check the blood pressure right away. D. Lay the patient flat with the legs raised.
C. Check the blood pressure right away. In a susceptible patient, a sudden severe headache calls for an immediate blood pressure check.
VERIFIED AGAINST THE SOURCE
“who complain of an acute, severe headache should immediately have their blood pressure checked”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗05In an adult, what rise in systolic blood pressure above baseline objectively defines an episode of autonomic dysreflexia? A. At least 5 mm Hg. B. At least 20 mm Hg. C. At least 60 mm Hg. D. At least 100 mm Hg.
B. At least 20 mm Hg. An adult episode is defined as a systolic rise of at least 20 mm Hg above baseline.
VERIFIED AGAINST THE SOURCE
“An episode of autonomic dysreflexia is objectively defined as an increase in systolic blood pressure of at least 20 mm Hg above baseline in adults”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗06In a child, what rise in systolic blood pressure above baseline defines an episode of autonomic dysreflexia? A. 15 mm Hg. B. 5 mm Hg. C. 30 mm Hg. D. 50 mm Hg.
A. 15 mm Hg. The threshold for children is lower than for adults: 15 mm Hg above baseline.
VERIFIED AGAINST THE SOURCE
“increase in systolic blood pressure of at least 20 mm Hg above baseline in adults and 15 mm Hg in children”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗07What resting systolic blood pressure is typical for a person with a spinal cord injury at T6 or higher? A. 140 to 160 mm Hg. B. 160 to 180 mm Hg. C. 60 to 70 mm Hg. D. 90 to 110 mm Hg.
D. 90 to 110 mm Hg. Baseline pressures run low, about 90 to 110 mm Hg, so a reading that looks normal may be high for this patient.
VERIFIED AGAINST THE SOURCE
“Patients with injuries at T6 or higher levels generally tend to have systolic blood pressures between 90 and 110 mm Hg.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗08Which heart rate change is most typical during an autonomic dysreflexia episode, and why? A. Tachycardia, from blood loss. B. Tachycardia, from fever. C. Bradycardia, from compensatory vagal stimulation. D. No change, because the heart is denervated.
C. Bradycardia, from compensatory vagal stimulation. The vagal and parasympathetic response slows the heart, but its vasodilating effect reaches only above the injury.
VERIFIED AGAINST THE SOURCE
“The compensatory vagal and parasympathetic stimulation leads to bradycardia and vasodilation, but only above the level of the spinal cord injury.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗09Where on the body does a patient in autonomic dysreflexia usually flush and sweat heavily? A. Below the level of the injury only. B. Above the level of the injury, such as the face, neck and shoulders. C. On the feet and lower legs. D. Evenly over the whole body.
B. Above the level of the injury, such as the face, neck and shoulders. Compensatory vasodilation above the injury causes flushing and sweating of the face, neck and shoulders.
VERIFIED AGAINST THE SOURCE
“Profuse sweating (diaphoresis) and flushing above the level of injury”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗10How does the skin below the level of injury usually look during autonomic dysreflexia? A. Cold and pale. B. Warm and flushed. C. Hot and dry. D. Bright red and sweaty.
A. Cold and pale. Intense sympathetic vasoconstriction below the injury leaves the skin there cold and pale.
VERIFIED AGAINST THE SOURCE
“Cold, pale skin below the level of injury due to severe sympathetic-induced vasoconstriction”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗11During an episode, where do goose bumps (piloerection) appear? A. Above the level of the injury only. B. On the face only. C. They never occur in this condition. D. Below the level of the spinal injury.
D. Below the level of the spinal injury. Piloerection appears below the level of the injury, where sympathetic activity is unchecked.
VERIFIED AGAINST THE SOURCE
“Piloerection (goose bumps) below the level of the spinal injury”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗12Why does the blood pressure keep rising in autonomic dysreflexia even though the brain senses it? A. The kidneys stop filtering blood. B. The baroreceptors are destroyed by the injury. C. The corrective parasympathetic signal cannot travel below the injury. D. The heart rate rises too fast to fill.
C. The corrective parasympathetic signal cannot travel below the injury. The brain tries to correct the pressure, but its parasympathetic signal cannot pass the injury, so vasoconstriction below it goes on.
VERIFIED AGAINST THE SOURCE
“the normal corrective parasympathetic response from the medullary vasomotor center cannot travel below the level of the spinal injury”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗13Constriction of which vascular bed drives the severe hypertension in autonomic dysreflexia? A. The coronary arteries. B. The splanchnic vasculature. C. The cerebral arteries. D. The pulmonary veins.
B. The splanchnic vasculature. Lesions at or above T6 allow intense sympathetic constriction of the splanchnic bed, the body's largest circulatory reserve.
VERIFIED AGAINST THE SOURCE
“Spinal cord lesions at or above T6 cause intense sympathetic stimulation to constrict the splanchnic vasculature”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗14Why is autonomic dysreflexia rare after a spinal cord injury below T10? A. Splanchnic innervation stays intact, so the gut vessels can still dilate. B. The bladder cannot fill after such an injury. C. Those patients have no sympathetic nerves. D. Their baseline blood pressure is too high.
A. Splanchnic innervation stays intact, so the gut vessels can still dilate. Below T10 the splanchnic nerves still receive control, allowing compensatory dilation.
VERIFIED AGAINST THE SOURCE
“Spinal cord injuries below T10 rarely result in autonomic dysreflexia because the splanchnic innervation remains intact”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗15A patient with quadriplegia is in suspected autonomic dysreflexia. How should the nurse position the patient first? A. Flat on the back with the legs raised. B. Prone with the head turned. C. Left side with the knees to the chest. D. Sit upright with the legs dangling, and loosen tight clothing.
D. Sit upright with the legs dangling, and loosen tight clothing. Sitting up with the legs down lowers pressure, and loosening clothing, belts and binders removes possible triggers.
VERIFIED AGAINST THE SOURCE
“Sit the patient upright with their legs dangling and remove or release any tight clothing, shoes, belts, binders, or constrictive devices.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗16How does sitting a patient upright with the legs down help in autonomic dysreflexia? A. It empties the bladder by gravity alone. B. It raises the heart rate. C. Blood pools in the abdomen and legs, lowering the pressure. D. It increases blood flow to the brain.
C. Blood pools in the abdomen and legs, lowering the pressure. The upright position lowers pressure orthostatically by pooling blood in the abdominal and leg vessels.
VERIFIED AGAINST THE SOURCE
“Sitting up helps lower their blood pressure orthostatically by inducing blood pooling in the abdominal and lower extremity vessels”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗17How often should vital signs be checked during an acute episode until the patient is stable? A. Every 30 minutes. B. About every 2 to 3 minutes. C. Every hour. D. Once at the start, then at discharge.
B. About every 2 to 3 minutes. Pressure can change quickly, so vital signs are checked every 2 to 3 minutes until stable.
VERIFIED AGAINST THE SOURCE
“Vital signs should be closely monitored, such as every 2 to 3 minutes, until stable.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗18Which possible trigger should be checked first in an acute episode? A. Bladder drainage. B. The toenails. C. Room temperature. D. Recent meals.
A. Bladder drainage. Because the bladder is the most likely source, restoring bladder drainage is the first step in the search.
VERIFIED AGAINST THE SOURCE
“immediate evaluation and restoration of bladder drainage is recommended as the first and most likely potential triggering source to investigate”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗19A patient in autonomic dysreflexia has an indwelling urinary catheter. What should the nurse look for first? A. The color of the urine only. B. The date printed on the drainage bag. C. Whether the bag is above the bladder. D. Kinks, folds, blockages or other obstruction in the catheter and tubing.
D. Kinks, folds, blockages or other obstruction in the catheter and tubing. A kinked or blocked catheter is a common, quickly fixed cause, so the catheter and tubing are checked first.
VERIFIED AGAINST THE SOURCE
“Check the catheter and tubing carefully for blockages, constrictions, folds, kinks, stones, or obstructions.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗20Why should catheter irrigation fluid be warmed during autonomic dysreflexia? A. Warm fluid dissolves kidney stones. B. Warm fluid kills bacteria in the bladder. C. Cold fluid could trigger more dysreflexic reactions. D. Cold fluid freezes the balloon.
C. Cold fluid could trigger more dysreflexic reactions. Cold irrigation fluid is itself a stimulus that could worsen the episode.
VERIFIED AGAINST THE SOURCE
“Warmed normal saline should be used for catheter irrigation, as cold fluids could trigger further dysreflexic reactions.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗21When irrigating an indwelling catheter during an episode, how much fluid should be used? A. A large volume, quickly. B. A small volume, gently. C. Enough to fill the bladder fully. D. Fluid should never be used.
B. A small volume, gently. Gentle irrigation with a small volume tests patency without distending the bladder further.
VERIFIED AGAINST THE SOURCE
“Gently irrigate the catheter with a small volume of sterile irrigation fluid, preferably at body temperature.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗22The indwelling catheter will not irrigate easily during an episode. What is the next step? A. Change the catheter immediately. B. Wait an hour and try again. C. Clamp the catheter. D. Push harder on the syringe.
A. Change the catheter immediately. A catheter that does not irrigate easily should be replaced at once to restore drainage.
VERIFIED AGAINST THE SOURCE
“If the Foley catheter does not irrigate easily, change it immediately!”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗23A patient in an episode has no indwelling catheter. What should be done for the bladder? A. Encourage oral fluids. B. Apply a heating pad over the bladder. C. Wait for spontaneous voiding. D. Catheterize the bladder immediately.
D. Catheterize the bladder immediately. Without an indwelling catheter, the bladder should be catheterized right away to relieve possible distention.
VERIFIED AGAINST THE SOURCE
“If the patient does not have an indwelling Foley, immediate catheterization of the bladder should be performed.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗24What should the nurse avoid doing over the bladder during an episode? A. Looking for distention. B. Using a bladder scanner. C. Pressing, tapping or palpating it unduly. D. Recording urine output.
C. Pressing, tapping or palpating it unduly. Pressing, tapping or palpating the bladder can make the dysreflexia worse.
VERIFIED AGAINST THE SOURCE
“Avoid undue suprapubic pressing, tapping, or palpating the bladder, as this may exacerbate dysreflexia.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗25The nurse cannot pass a standard urinary catheter during an episode. Which catheter is recommended? A. A smaller condom catheter. B. A coude catheter, or a council tip catheter over a guidewire. C. A rectal tube. D. A nasogastric tube.
B. A coude catheter, or a council tip catheter over a guidewire. A coude catheter, or a council tip catheter with a guidewire, is recommended when the first attempt is difficult.
VERIFIED AGAINST THE SOURCE
“A coude catheter or a guidewire and a council tip catheter are recommended if difficulty is encountered in the initial placement of the Foley.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗26Why can catheter insertion be harder during autonomic dysreflexia? A. High sympathetic tone can tighten the urethral sphincter. B. The bladder shrinks during an episode. C. The urethra becomes numb. D. Urine production stops.
A. High sympathetic tone can tighten the urethral sphincter. The surge of sympathetic tone can tighten the urethral sphincter.
VERIFIED AGAINST THE SOURCE
“the increased sympathetic tone can tighten the urethral sphincter”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗27A badly overdistended bladder is being drained after an antihypertensive was given. What must the nurse watch for? A. Rising blood glucose. B. Sudden fever. C. Rising potassium. D. Rebound hypotension, so blood pressure is monitored during drainage.
D. Rebound hypotension, so blood pressure is monitored during drainage. Draining a very full bladder, especially after an antihypertensive, can drop the pressure sharply.
VERIFIED AGAINST THE SOURCE
“Blood pressure should be monitored carefully during bladder drainage in patients with known bladder overdistension.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗28The bladder is not distended and the catheter drains well, but the episode continues. What is the most likely cause? A. A pressure-free skin surface. B. Low room humidity. C. A bowel problem such as fecal impaction. D. Dehydration.
C. A bowel problem such as fecal impaction. Once the bladder is ruled out, fecal impaction is the next most likely trigger.
VERIFIED AGAINST THE SOURCE
“If the bladder is not distended and the Foley catheter is draining adequately, but the autonomic dysreflexic episode persists, a bowel issue, such as fecal impaction, is the most likely cause.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗29When a bowel trigger is suspected, what should be avoided? A. Gentle assessment of the abdomen. B. Large-volume enemas and vigorous rectal stimulation. C. Asking about the last bowel movement. D. Reviewing the bowel program.
B. Large-volume enemas and vigorous rectal stimulation. A suppository can be used, but large-volume enemas and vigorous manual or digital stimulation should be avoided.
VERIFIED AGAINST THE SOURCE
“A suppository can be used, but large-volume enemas and vigorous manual or digital rectal stimulation should be avoided.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗30Systolic pressure is 170 mm Hg and a fecal impaction is suspected. What should happen before the rectal exam? A. Give an antihypertensive to lower the pressure first. B. Do the rectal exam at once without medication. C. Give a large-volume enema. D. Lay the patient flat first.
A. Give an antihypertensive to lower the pressure first. When systolic pressure is over 150 mm Hg, drug therapy should lower it before any rectal examination.
VERIFIED AGAINST THE SOURCE
“pharmacological therapy should be initiated to reduce it before rectal examinations”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗31Which drug is the recommended first-line treatment for severe hypertension in autonomic dysreflexia? A. Oral furosemide. B. Oral metoprolol. C. Intramuscular epinephrine. D. Nitroglycerin 2% paste.
D. Nitroglycerin 2% paste. Nitroglycerin 2% paste is the recommended first-line agent, especially when systolic pressure is over 150 mm Hg.
VERIFIED AGAINST THE SOURCE
“Nitroglycerin 2% paste is the recommended first-line treatment for severe hypertension in patients experiencing autonomic dysreflexia”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗32Where should nitroglycerin 2% paste be applied for autonomic dysreflexia? A. On the feet. B. On the skin below the injury. C. On the skin above the level of the spinal cord injury. D. Inside the mouth.
C. On the skin above the level of the spinal cord injury. About 1 to 2 inches of paste go on the skin above the level of injury.
VERIFIED AGAINST THE SOURCE
“Approximately 1 to 2 inches of nitroglycerin 2% paste should be placed on the skin above the level of the spinal cord injury.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗33What practical advantage does nitroglycerin paste have once the crisis passes? A. It works only for 30 seconds. B. It can easily be wiped off. C. It needs no blood pressure checks. D. It also empties the bladder.
B. It can easily be wiped off. The paste can simply be removed when the hypertensive crisis is over, which helps limit hypotension.
VERIFIED AGAINST THE SOURCE
“The nitroglycerin paste can easily be removed when the hypertensive crisis is over.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗34How should nitroglycerin paste be put on the skin? A. Spread lightly without rubbing it in, then cover it with plastic wrap or waterproof tape. B. Rub it in hard until it disappears. C. Leave it uncovered so it dries. D. Mix it with lotion first.
A. Spread lightly without rubbing it in, then cover it with plastic wrap or waterproof tape. The paste is spread lightly, not rubbed in, and covered to hold it in place.
VERIFIED AGAINST THE SOURCE
“When applying the nitroglycerin paste, spread the gel lightly on the skin and avoid rubbing it in.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗35Before giving a nitrate for autonomic dysreflexia, what must the nurse ask? A. Whether the patient ate in the last hour. B. Whether the patient has had a flu shot. C. Whether the patient wears glasses. D. Whether the patient recently took a phosphodiesterase inhibitor such as sildenafil.
D. Whether the patient recently took a phosphodiesterase inhibitor such as sildenafil. Phosphodiesterase inhibitors add to the blood-pressure-lowering effect of nitrates.
VERIFIED AGAINST THE SOURCE
“Before administering a nitrate-based antihypertensive, determine whether the patient has recently taken a phosphodiesterase inhibitor, such as sildenafil”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗36A patient took tadalafil yesterday. For how long after a tadalafil dose should nitrates be avoided? A. 2 hours. B. 6 hours. C. 48 hours. D. 12 hours.
C. 48 hours. Nitrates are avoided within 24 hours of sildenafil and within 48 hours of tadalafil because of severe hypotension.
VERIFIED AGAINST THE SOURCE
“should not be administered to patients who have taken sildenafil or similar medications within 24 hours (or within 48 hours of taking tadalafil)”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗37Why is sublingual nifedipine not recommended for autonomic dysreflexia? A. It never lowers blood pressure. B. Its absorption is unpredictable. C. It works only in children. D. It must be given into a vein.
B. Its absorption is unpredictable. The sublingual route absorbs unpredictably; the capsule is given bite-and-swallow instead.
VERIFIED AGAINST THE SOURCE
“Sublingual nifedipine is not recommended due to its unpredictable absorption.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗38How is immediate-release nifedipine given for autonomic dysreflexia? A. By the bite-and-swallow technique. B. Dissolved under the tongue. C. As a skin patch. D. As a rectal suppository.
A. By the bite-and-swallow technique. The capsule is given with a bite-and-swallow technique.
VERIFIED AGAINST THE SOURCE
“The capsule should be administered using a bite-and-swallow technique.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗39What is the usual starting dose of immediate-release nifedipine for an episode? A. 1 mg. B. 60 mg. C. 120 mg. D. 10 mg.
D. 10 mg. Immediate-release nifedipine 10 mg is a recommended initial drug when treatment is needed.
VERIFIED AGAINST THE SOURCE
“Immediate-release nifedipine 10 mg is also recommended as an appropriate initial medical pharmacotherapy”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗40What is the maximum nifedipine dose for autonomic dysreflexia in 24 hours? A. 10 mg. B. 100 mg. C. 40 mg. D. There is no maximum.
C. 40 mg. Doses may be repeated every 20 to 30 minutes up to 40 mg in 24 hours.
VERIFIED AGAINST THE SOURCE
“The treatment should be repeated every 20 to 30 minutes, up to a maximum of 40 mg/24 hours.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗41In which patient is nifedipine not recommended for autonomic dysreflexia? A. A patient with a T4 injury. B. A patient with coronary artery disease. C. A patient with a urinary catheter. D. A patient under 50 years old.
B. A patient with coronary artery disease. Nifedipine is not recommended when the patient has coronary artery disease.
VERIFIED AGAINST THE SOURCE
“Nifedipine is not recommended in patients with coronary artery disease.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗42An older adult already takes other antihypertensives. How is the nifedipine dose adjusted? A. Reduced to 5 mg. B. Doubled to 20 mg. C. Given intravenously. D. Not changed.
A. Reduced to 5 mg. The dose is cut to 5 mg in older people and in those on other blood pressure drugs.
VERIFIED AGAINST THE SOURCE
“The dose should be reduced to 5 mg in older individuals and those taking other antihypertensive medications.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗43What kind of antihypertensive is preferred for an autonomic dysreflexia crisis? A. One with a slow onset and long duration. B. One taken once a week. C. One that also raises heart rate. D. One with a rapid onset and short duration of action.
D. One with a rapid onset and short duration of action. Fast-acting, short-lived agents lower the pressure quickly but wear off once the trigger is removed.
VERIFIED AGAINST THE SOURCE
“Hypertension should be promptly corrected with agents that optimally have a rapid onset but short duration of action.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗44After emergency antihypertensive treatment, how long should blood pressure monitoring continue? A. 10 minutes. B. Until the next shift only. C. At least 2 more hours. D. No monitoring is needed.
C. At least 2 more hours. Pressure is monitored for at least an additional 2 hours after emergency treatment.
VERIFIED AGAINST THE SOURCE
“After emergency hypertensive treatment, the patient's blood pressure should be monitored for at least an additional 2 hours.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗45For how long after antihypertensive drugs, especially nitrates, can rebound hypotension occur? A. Up to 5 minutes. B. Up to 5 hours. C. Up to 5 days. D. It does not occur.
B. Up to 5 hours. Rebound hypotension can occur for 5 hours, so frequent pressure checks are needed.
VERIFIED AGAINST THE SOURCE
“Rebound hypotension can occur for 5 hours after administration of antihypertensive medications, particularly nitrates”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗46When should transfer to an intensive care unit be considered? A. When the hypertensive crisis is not controlled within 30 minutes. B. As soon as the headache starts. C. Only after 24 hours of symptoms. D. Never; episodes are always managed on the floor.
A. When the hypertensive crisis is not controlled within 30 minutes. ICU transfer is considered if the crisis is not controlled within 30 minutes.
VERIFIED AGAINST THE SOURCE
“Transfer to an intensive care unit should be considered if autonomic dysreflexia and its associated hypertensive crisis are not controlled within 30 minutes.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗47Which situation is a reason to admit a patient after an autonomic dysreflexia episode? A. The catheter was changed and pressure normalized. B. The patient has had episodes before. C. The patient has a home blood pressure cuff. D. The cause of the episode is still unknown.
D. The cause of the episode is still unknown. Admission is recommended for poor response to treatment, an unknown cause, or pregnancy.
VERIFIED AGAINST THE SOURCE
“Hospital admission is recommended if the patient is responding poorly to treatment, if the underlying etiology of the episode remains unknown, or if the patient is pregnant.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗48A patient at risk has dysreflexia-like symptoms but a normal blood pressure. What is most likely? A. This is a severe episode. B. The blood pressure cuff must be broken. C. The patient most likely does not have autonomic dysreflexia. D. Nitroglycerin paste should be applied.
C. The patient most likely does not have autonomic dysreflexia. Without hypertension, the symptoms are most likely not autonomic dysreflexia.
VERIFIED AGAINST THE SOURCE
“Patients with symptoms of autonomic dysreflexia who do not have hypertension most likely do not have the disorder.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗49Can autonomic dysreflexia occur without any symptoms? A. No; a headache is always present. B. Yes; silent episodes still carry dangerous hypertension. C. No; it always causes fainting. D. Only in children.
B. Yes; silent episodes still carry dangerous hypertension. Silent episodes happen, and the high pressure still risks stroke and other complications.
VERIFIED AGAINST THE SOURCE
“Autonomic dysreflexia events can be silent and not present with clinical symptoms.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗50What is considered the most serious complication of autonomic dysreflexia? A. Hemorrhagic stroke. B. Mild nasal congestion. C. Goose bumps. D. Short-lived anxiety.
A. Hemorrhagic stroke. Hemorrhagic stroke is the most serious complication and can be fatal.
VERIFIED AGAINST THE SOURCE
“A hemorrhagic stroke is considered the most serious complication of autonomic dysreflexia”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗51Which rectal problems can trigger autonomic dysreflexia? A. Only a full stomach. B. Only a dry mouth. C. Only nasal congestion. D. Hemorrhoids, anal abscess or fissure.
D. Hemorrhoids, anal abscess or fissure. Back-passage problems such as hemorrhoids, an abscess or a fissure are listed triggers.
VERIFIED AGAINST THE SOURCE
“Back passage (hemorrhoids, rectal issues, anal abscess, fissure)”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗52Which skin or body problem below the injury can set off an episode? A. A clean, dry, loose-fitting gown. B. A normal bowel movement. C. An ingrown toenail or tight clothing. D. A warm, comfortable room.
C. An ingrown toenail or tight clothing. Pressure ulcers, skin infections, ingrown toenails, burns, fractures, tight clothing and temperature swings are triggers.
VERIFIED AGAINST THE SOURCE
“pressure ulcers, skin infections, ingrown toenails, burns, bone fractures, tight clothing, significant temperature changes”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗53Which medications can trigger autonomic dysreflexia? A. Acetaminophen. B. Nasal decongestants and sympathomimetic drugs. C. Normal saline flushes. D. Vitamin D.
B. Nasal decongestants and sympathomimetic drugs. Nasal decongestants, sympathomimetics and misoprostol are named medication triggers.
VERIFIED AGAINST THE SOURCE
“medication effects, such as nasal decongestants, sympathomimetic drugs, and misoprostol”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗54When does autonomic dysreflexia usually first appear after a spinal cord injury? A. After spinal shock resolves, typically within 1 year. B. Within the first hour of injury. C. Only after 10 years. D. Only during sleep.
A. After spinal shock resolves, typically within 1 year. It generally does not develop until spinal shock has resolved, usually within the first year.
VERIFIED AGAINST THE SOURCE
“it generally does not develop until after the period of spinal shock resolves, typically within 1 year of the original injury”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗55How does a complete injury compare with an incomplete one for autonomic dysreflexia risk? A. Incomplete injuries carry the higher risk. B. The risk is identical. C. Complete injuries cannot develop it. D. Complete injuries are more than 3 times as likely to develop it.
D. Complete injuries are more than 3 times as likely to develop it. Patients with complete injuries are more than three times as likely to develop it.
VERIFIED AGAINST THE SOURCE
“Patients with a complete spinal cord injury are more than 3 times as likely to develop autonomic dysreflexia than those with incomplete injuries”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗56How often can episodes occur in a susceptible person? A. Only once in a lifetime. B. Only once per year. C. Up to 40 times per day. D. Only during illness.
C. Up to 40 times per day. Episodes can occur up to 40 times a day in susceptible individuals.
VERIFIED AGAINST THE SOURCE
“Autonomic dysreflexia can occur up to 40 times per day in susceptible individuals.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗57Which receptor change below the lesion adds to the blood pressure surge? A. Loss of all insulin receptors. B. Hypersensitive vascular alpha-adrenergic receptors. C. Blocked histamine receptors. D. Inactive opioid receptors.
B. Hypersensitive vascular alpha-adrenergic receptors. Vascular alpha-adrenergic receptors below the lesion become hypersensitive.
VERIFIED AGAINST THE SOURCE
“Another contributory mechanism is the hypersensitivity of vascular alpha-adrenergic receptors below the level of the spinal cord lesion.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗58What causes the pounding headache in autonomic dysreflexia? A. Marked vasodilation above the level of injury. B. Low blood sugar. C. Dehydration of the brain. D. Eye strain.
A. Marked vasodilation above the level of injury. The headache comes from significant vasodilation above the injury level.
VERIFIED AGAINST THE SOURCE
“resulting from significant vasodilation superior to the level of injury”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗59A patient has only mild symptoms. Can the nurse assume the blood pressure is only mildly raised? A. Yes; mild symptoms always mean mild hypertension. B. Yes; pressure need not be checked. C. No; mild symptoms mean hypotension. D. No; symptoms may not match how high the pressure is.
D. No; symptoms may not match how high the pressure is. Symptoms may not correlate with the severity of the blood pressure rise, so it must be measured.
VERIFIED AGAINST THE SOURCE
“Symptoms may not necessarily correlate with the severity of blood pressure elevation.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗60A patient with quadriplegia is found unconscious. What should be checked right away? A. Only the blood sugar. B. Only the temperature. C. Blood pressure, to screen for autonomic dysreflexia. D. Only the pupils.
C. Blood pressure, to screen for autonomic dysreflexia. Any person with paraplegia or quadriplegia who is found unconscious or reports a severe headache needs a blood pressure check.
VERIFIED AGAINST THE SOURCE
“Any patient with paraplegia or quadriplegia who complains of a severe headache or is found unconscious should immediately undergo screening for possible autonomic dysreflexia by checking their blood pressure.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗61Systolic pressure is above 150 mm Hg and the catheter still needs changing. What should the nurse consider? A. Waiting until the catheter is changed before any drug. B. Immediate antihypertensive therapy without waiting for the catheter change. C. Lying the patient flat. D. Giving a decongestant.
B. Immediate antihypertensive therapy without waiting for the catheter change. Above 150 mm Hg, immediate antihypertensive therapy is considered without waiting for other steps.
VERIFIED AGAINST THE SOURCE
“Patients with hypertension >150 mm Hg should be considered for immediate antihypertensive therapy without waiting for a catheter change or other treatment.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗62How is orthostatic hypotension defined in a patient with spinal cord injury? A. A drop in systolic pressure of 20 mm Hg or more on moving upright from lying supine. B. A rise in systolic pressure of 20 mm Hg on standing. C. A heart rate above 100 when lying down. D. Any systolic pressure under 140.
A. A drop in systolic pressure of 20 mm Hg or more on moving upright from lying supine. A fall of 20 mm Hg or more in systolic pressure when moving upright after lying supine defines it.
VERIFIED AGAINST THE SOURCE
“This condition is defined as a decrease in systolic blood pressure of 20 mm Hg or more when assuming an upright position after lying supine.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗63Why is skin temperature unreliable in a patient with a high spinal cord injury? A. Skin thermometers do not work on adults. B. Skin is always hot after injury. C. Core temperature cannot be measured. D. Body temperature control is impaired; a core reading is needed.
D. Body temperature control is impaired; a core reading is needed. A core temperature from an oral, tympanic or rectal probe is needed instead.
VERIFIED AGAINST THE SOURCE
“Skin temperature determinations are unreliable in these situations, so a core temperature reading from an oral, tympanic, or rectal probe is needed.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗64A patient with a spinal cord injury is cold. How should the nurse warm them? A. With a heating pad on the legs. B. With a hot water bottle under the feet. C. With blankets and warm fluids, not heating devices that could injure the skin. D. With a heat lamp close to the skin.
C. With blankets and warm fluids, not heating devices that could injure the skin. Warming avoids heating devices because of the risk of unnoticed skin damage.
VERIFIED AGAINST THE SOURCE
“without using heating devices to avoid inadvertent skin damage”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗65Who should carry an emergency autonomic dysreflexia kit? A. Only hospital staff. B. Anyone with a spinal cord injury who has had at least 1 significant episode. C. Only patients with injuries below T10. D. No one; kits are not advised.
B. Anyone with a spinal cord injury who has had at least 1 significant episode. Anyone who has had a significant episode should always carry a treatment kit.
VERIFIED AGAINST THE SOURCE
“any patient with a spinal cord injury who has had at least 1 significant episode of autonomic dysreflexia”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗66What should a patient emergency card for autonomic dysreflexia include? A. Causes of prior episodes and the baseline blood pressure. B. Only the home address. C. Only insurance details. D. Only a list of allergies to food.
A. Causes of prior episodes and the baseline blood pressure. The card lists the causes of past episodes and the baseline blood pressure, among other details.
VERIFIED AGAINST THE SOURCE
“causes of prior episodes of autonomic dysreflexia, and baseline blood pressure”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗67A patient with a known history arrives in an episode. What useful question should staff ask? A. When did you last travel abroad? B. Do you have a family history of migraine? C. What is your shoe size? D. What usually triggers your episodes and what usually fixes them?
D. What usually triggers your episodes and what usually fixes them? Patients know their own most common trigger and usual remedy.
VERIFIED AGAINST THE SOURCE
“they should be asked about their most common precipitating event and their usual remedy”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗68What home equipment should patients at risk have? A. A home ECG machine. B. A home ventilator. C. A home blood pressure monitor. D. A home glucose clamp.
C. A home blood pressure monitor. Patients should have home blood pressure monitoring devices.
VERIFIED AGAINST THE SOURCE
“Patients should also have home blood pressure monitoring devices.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗69How might bladder management change to prevent recurrent episodes? A. Stopping all catheterization. B. Intermittent self-catheterization more often, about 5 to 6 times a day. C. Catheterizing once a week. D. Restricting all fluids.
B. Intermittent self-catheterization more often, about 5 to 6 times a day. More frequent intermittent self-catheterization can be advised.
VERIFIED AGAINST THE SOURCE
“patients may be asked to perform intermittent self-catheterization more often (5-6 times a day)”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗70Is a daily antihypertensive taken only to prevent autonomic dysreflexia usually recommended? A. No, it is generally not recommended. B. Yes, for every patient with a spinal cord injury. C. Yes, but only at night. D. Yes, at double the usual dose.
A. No, it is generally not recommended. Daily antihypertensive drugs solely for prophylaxis are generally not recommended.
VERIFIED AGAINST THE SOURCE
“Daily antihypertensive medication solely for autonomic dysreflexia prophylaxis is generally not recommended.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗71Which bladder treatment has been shown to reduce the incidence of autonomic dysreflexia? A. Daily cranberry juice. B. Restricting fluids to 500 mL a day. C. Removing the catheter permanently. D. Botulinum toxin injections into the bladder muscle.
D. Botulinum toxin injections into the bladder muscle. Chemical denervation of the bladder muscle with botulinum toxin reduces episodes.
VERIFIED AGAINST THE SOURCE
“Botulinum toxin injections for chemical denervation of the bladder muscle have been shown to reduce the incidence of autonomic dysreflexia”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗72Which routine helps prevent skin-related triggers? A. Checking the skin once a year. B. Avoiding all position changes. C. Periodic skin inspections to catch ulcers and breakdown. D. Wearing tighter clothing.
C. Periodic skin inspections to catch ulcers and breakdown. Regular skin inspections minimize ulcers and skin breakdown.
VERIFIED AGAINST THE SOURCE
“periodic inspections for skin lesions to minimize ulcers and skin breakdowns”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗73When should blood pressure be checked after sexual activity in a person at risk? A. 24 hours later. B. 5 minutes after finishing. C. Only if a headache lasts a week. D. It does not need checking.
B. 5 minutes after finishing. Pressure should be checked 5 minutes after completing sexual activity.
VERIFIED AGAINST THE SOURCE
“Patients should have their blood pressure checked 5 minutes after completing sexual activity.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗74Why is prazosin a poor choice for preventing episodes linked to unplanned sexual activity? A. It needs pretreatment 12 hours beforehand. B. It only works for 1 minute. C. It raises blood pressure. D. It must be given intravenously.
A. It needs pretreatment 12 hours beforehand. Prazosin requires pretreatment 12 hours before intercourse.
VERIFIED AGAINST THE SOURCE
“prazosin requires pretreatment 12 hours before intercourse, making it unsuitable for spontaneous, unplanned sexual activities”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗75How might labor present in a pregnant patient with a high spinal cord injury? A. Always with severe typical labor pain. B. Only with fever. C. Only with a low heart rate in the mother. D. Only mild abdominal discomfort, more spasticity and autonomic dysreflexia.
D. Only mild abdominal discomfort, more spasticity and autonomic dysreflexia. Labor may show only abdominal discomfort, increased spasticity and dysreflexia.
VERIFIED AGAINST THE SOURCE
“the symptoms of labor may include only some abdominal discomfort, increased spasticity, and autonomic dysreflexia”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗76Which anesthesia is reported as the best choice for controlling autonomic dysreflexia in labor? A. No anesthesia. B. Local skin anesthetic only. C. Epidural anesthesia. D. Oral sedatives only.
C. Epidural anesthesia. Epidural anesthesia has been reported as the best choice during labor.
VERIFIED AGAINST THE SOURCE
“Epidural anesthesia has been reportedly the best choice for controlling autonomic dysreflexia during labor.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗77An episode begins during a urologic procedure. What should be done first? A. Speed the procedure up to finish faster. B. Stop the procedure and promptly drain the bladder. C. Give ephedrine. D. Lay the patient flat and wait.
B. Stop the procedure and promptly drain the bladder. The activity is stopped at once and the bladder promptly drained.
VERIFIED AGAINST THE SOURCE
“the activity should be immediately terminated and the bladder promptly drained”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗78An episode starts during surgery under general anesthesia. What often relieves it? A. Deepening the anesthesia. B. Lightening the anesthesia. C. Giving ephedrine. D. Cooling the room.
A. Deepening the anesthesia. Increasing the anesthetic agent to deepen anesthesia often settles the episode.
VERIFIED AGAINST THE SOURCE
“deepening the level of anesthesia by increasing the anesthetic agent often alleviates the episode”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗79Which drug should be avoided around procedures in patients prone to autonomic dysreflexia? A. Nitroglycerin paste. B. Nifedipine. C. Lidocaine gel. D. Ephedrine.
D. Ephedrine. Drugs that raise blood pressure, such as ephedrine, should be avoided.
VERIFIED AGAINST THE SOURCE
“avoid any drugs that could elevate blood pressure, such as ephedrine”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗80How often should blood pressure be measured during a procedure that could trigger an episode? A. Every 30 minutes. B. Once at the start. C. Continuously or at least every 2 minutes. D. Only at the end.
C. Continuously or at least every 2 minutes. Monitor continuously or at least every 2 minutes in susceptible patients.
VERIFIED AGAINST THE SOURCE
“Monitor blood pressure either continuously or at least every 2 minutes in susceptible individuals undergoing procedures that could induce autonomic dysreflexia.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗81What does "boosting" mean in spinal cord injury sport? A. Taking extra protein before a race. B. Deliberately triggering autonomic dysreflexia to improve performance. C. Using a lighter wheelchair. D. Warming up for longer.
B. Deliberately triggering autonomic dysreflexia to improve performance. Boosting is deliberately triggering an episode to enhance athletic performance.
VERIFIED AGAINST THE SOURCE
“Boosting refers to deliberately triggering an episode of autonomic dysreflexia to enhance athletic performance”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗82Which treatment is often the most effective immediate treatment for bladder spasms? A. A belladonna and opium (B & O) suppository. B. A large-volume enema. C. Cold water bladder irrigation. D. Suprapubic tapping.
A. A belladonna and opium (B & O) suppository. A B & O suppository is often the most effective immediate treatment for bladder spasms.
VERIFIED AGAINST THE SOURCE
“a belladonna and opium (B & O) suppository is often the most effective, immediate treatment for bladder spasms”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗83Which drugs can cause dysreflexia-like hypertension in people without a spinal cord injury? A. Acetaminophen. B. Antacids. C. Saline nasal spray. D. Stimulants such as cocaine and amphetamines.
D. Stimulants such as cocaine and amphetamines. Stimulant drugs are among the causes of similar episodes in people without spinal cord injury.
VERIFIED AGAINST THE SOURCE
“the underlying causes include stimulant drugs, such as cocaine and amphetamines”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗84Which member of the care team is often first to identify autonomic dysreflexia? A. The pharmacist. B. The dietitian. C. The nurse. D. The radiologist.
C. The nurse. Nurses monitor these patients closely and are often the first to identify the condition.
VERIFIED AGAINST THE SOURCE
“Nurses play a key role in monitoring patients with autonomic dysreflexia and are often the first healthcare personnel to identify the condition.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗85Besides dysreflexia, which complications are these patients also prone to? A. Cataracts and hearing loss only. B. Deep vein thrombosis and pressure sores. C. Tooth decay only. D. Hair loss only.
B. Deep vein thrombosis and pressure sores. Patients are also prone to deep vein thrombosis and pressure sores.
VERIFIED AGAINST THE SOURCE
“Autonomic dysreflexia patients are also prone to deep vein thrombosis and pressure sores”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗86Do most autonomic dysreflexia episodes need hospital care? A. No; most are mild and handled at home by the patient and caregivers. B. Yes; every episode needs an ICU. C. Yes; every episode needs surgery. D. No; episodes always stop without action.
A. No; most are mild and handled at home by the patient and caregivers. Most episodes are relatively mild and can be managed at home without acute medical care.
VERIFIED AGAINST THE SOURCE
“most episodes are relatively mild and can be managed at home by the patient and their usual caregivers”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗87For regional anesthesia in a patient at risk, to what level should the anesthetic extend? A. C2. B. L5. C. S5. D. T10.
D. T10. The anesthetic level should reach T10 to minimize the risk.
VERIFIED AGAINST THE SOURCE
“The anesthetic level should be extended to T10 to minimize the risk of autonomic dysreflexia.”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗88A continuous intravenous antihypertensive infusion is started. What monitoring is recommended? A. A blood pressure check once per shift. B. Pulse oximetry only. C. An arterial line for close monitoring and titration. D. No extra monitoring.
C. An arterial line for close monitoring and titration. An arterial line allows close monitoring and titration of the infusion.
VERIFIED AGAINST THE SOURCE
“placement of an arterial line is recommended for close monitoring and optimal titration of the infusion”
— StatPearls (StatPearls Publishing), NCBI Bookshelf, National Library of Medicine ↗Know questions we're missing?
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