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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Scheduled voiding relies on the patient’s ability to control bladder function, which is ineffective in cases of a flaccid bladder caused by spinal cord injuries.
Choice B rationale
External catheters, such as condom catheters, are suited for patients with partial bladder control but are not appropriate for flaccid or atonic bladder management.
Choice C rationale
Indwelling urinary catheters may be used short-term but pose higher risks of urinary tract infections and are not optimal for long-term management of flaccid bladder.
Choice D rationale
Intermittent catheterization is the preferred method for managing flaccid bladder, ensuring complete bladder emptying while minimizing infection risks compared to indwelling catheters.
Correct Answer is B
Explanation
Choice A rationale
Applying pressure to prevent drainage could force cerebrospinal fluid (CSF) back into the cranial cavity, increasing infection risk and intracranial pressure, potentially worsening brain injury. CSF leakage requires non-obstructive handling.
Choice B rationale
Allowing fluid to drain onto gauze prevents build-up of intracranial pressure while assessing for halo sign, indicating CSF leakage. Yellow staining reflects glucose presence in CSF, confirming dura mater damage.
Choice C rationale
Intravenous fluids manage hypovolemia but are not prioritized for trauma patient brain injuries. Replacing lost CSF requires specific medical intervention rather than fluid volume adjustments alone.
Choice D rationale
Antibiotics treat infections but are not first priority for confirmed CSF leakage, which demands careful monitoring of drainage to prevent neurological damage. Post-intervention antibiotics may be necessary.
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