A nurse is caring for a patient with a spinal cord injury who is about to be transferred to a wheelchair for physical therapy.
The patient complains of feeling dizzy and is diaphoretic.
What would be the priority nursing action?
Establish IV access and bolus 250 mL of normal saline.
Reschedule the therapy session for later in the day.
Lower the head of the bed and obtain vital signs.
Assess for bladder distention and perform digital disimpaction.
The Correct Answer is C
Choice A rationale
IV fluid bolus may address hypotension but is not the first priority. Symptoms of dizziness and diaphoresis in a spinal cord injury patient suggest autonomic dysreflexia or orthostatic hypotension requiring positional changes first.
Choice B rationale
Rescheduling therapy does not address the acute symptoms the patient is experiencing. Immediate action to manage dizziness and diaphoresis, such as altering body position, is required to stabilize the patient.
Choice C rationale
Lowering the head of the bed counters orthostatic hypotension, a common issue in spinal cord injury patients. Obtaining vital signs identifies the underlying cause and guides further interventions.
Choice D rationale
Bladder distention can trigger autonomic dysreflexia, but without evidence of urinary retention, prioritizing positional adjustments is more urgent to alleviate symptoms of dizziness and stabilize hemodynamics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hemiparesis on the right side and ataxia are common manifestations of left-sided stroke, where the motor cortex affecting the contralateral side is impaired, leading to muscle weakness and coordination loss.
Choice B rationale
Spasticity of the left arm suggests motor impairment on the ipsilateral side, which is inconsistent with the nature of left-sided strokes affecting the contralateral side. Apraxia lacks relation to motor loss here.
Choice C rationale
Impulsive behavior and hostility are more indicative of frontal lobe involvement, not motor loss secondary to left-sided strokes. These behaviors do not represent motor manifestations.
Choice D rationale
Visual defects like homonymous hemianopia and diplopia may occur in stroke but are not direct indicators of motor loss. They relate to occipital lobe or optic pathway damage.
Correct Answer is B
Explanation
Choice A rationale
Fluid intake does not directly impact intraocular pressure. Management of glaucoma focuses on medications like eye drops and surgical interventions rather than restricting fluid intake.
Choice B rationale
Glaucoma treatments, including eye drops, aim to manage intraocular pressure. These medications are required lifelong to prevent optic nerve damage and preserve vision.
Choice C rationale
Excess salt impacts systemic blood pressure but does not directly influence intraocular pressure. Glaucoma management targets ocular pressure, not dietary sodium reduction.
Choice D rationale
Avoiding eye overuse may reduce strain but does not address intraocular pressure. Effective glaucoma treatment relies on pharmacological or surgical measures rather than activity limitation.
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