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 C
Explanation
Choice A rationale
Detached retina typically does not present with sharp, stabbing pain. Instead, patients experience painless symptoms like vision abnormalities due to separation of the retina from supporting tissue.
Choice B rationale
Total vision loss is rare with a detached retina unless extensive damage occurs. Partial visual disruption, such as curtain-like vision loss, is a hallmark symptom.
Choice C rationale
A curtain-like loss of vision arises from retinal detachment, disrupting visual fields as the retina separates from its vascular supply and neural connections.
Choice D rationale
Yellow sclera discoloration is associated with jaundice due to bilirubin accumulation, unrelated to retinal detachment pathology, which affects visual symptoms and not scleral appearance.
Correct Answer is C
Explanation
Choice A rationale
Asking the patient why they are behaving inappropriately does not address or stop the behavior. This approach may escalate the situation, leading to further discomfort for others.
Choice B rationale
Recommending 1: observation without addressing the behavior does not teach social boundaries. It is a passive solution that misses the opportunity for behavior correction.
Choice C rationale
Pointing out the behavior as unacceptable sets clear boundaries and educates the patient on appropriate social conduct. It creates an opportunity for the patient to reflect and adjust their behavior.
Choice D rationale
Having the patient return to their room may temporarily stop the behavior but does not educate the patient or reinforce appropriate boundaries for public settings.
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