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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A rationale

Brown-Sequard injury results in ipsilateral motor function loss due to corticospinal tract damage and contralateral pain/temperature loss from spinothalamic tract disruption, characteristic of this hemisection spinal cord injury.

Choice B rationale

Central cord injury affects cervical spine and hand function but does not exhibit hemisection symptoms like ipsilateral motor loss or contralateral sensory loss. Symptoms vary and commonly include upper limb weakness.

Choice C rationale

Posterior cord injury primarily impacts dorsal column function, resulting in loss of proprioception and vibration sense. Motor and pain/temperature functions are preserved, unlike in Brown-Sequard injury.

Choice D rationale

Anterior cord injury involves ischemic damage to the anterior spinal artery, leading to motor paralysis and pain/temperature loss bilaterally, not ipsilateral and contralateral as described in the question.

A. Nitroprusside. B. 3% Normal Saline. C. Furosemide. D. Norepinephrine.

Correct Answer is B

Explanation

Choice A rationale

Nitroprusside is a vasodilator for hypertensive crises but is contraindicated in elevated ICP because it increases cerebral blood volume and exacerbates intracranial pressure, worsening the patient's condition.

Choice B rationale

Hypertonic saline (3%) helps reduce ICP by drawing excess fluid from brain tissue into the bloodstream through osmosis, effectively lowering intracranial pressure while maintaining cerebral perfusion.

Choice C rationale

Furosemide is a loop diuretic that reduces fluid overload but does not specifically target ICP. It is less effective in managing the osmotic balance required for intracranial pressure reduction.

Choice D rationale

Norepinephrine is a vasopressor used to treat hypotension and improve perfusion but does not lower ICP and may increase cerebral vasoconstriction, exacerbating intracranial hypertension. .

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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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?