The nurse assesses the patient with a spinal cord injury at the level C-7 and finds warm, flushed skin with profuse sweating above the level of injury, and pale, cold skin below the level of injury. The patient is bradycardic, but severely hypertensive. What are the priority nursing interventions?

Establish IV access apply 2L O2 via nasal cannula, and notify provider

Assess below injury for noxious stimuli anticipate order hypertensive medication

Administer acetaminophen and initiate intravenous (IV) fluids anticipate order for atropine

Lower the head of the bed and apply a cool compress to the forehead

Answer and Explanation

The Correct Answer is B

A) Establish IV access, apply 2L O2 via nasal cannula, and notify provider:
While establishing IV access and providing oxygen are important aspects of managing many emergencies, this patient's symptoms suggest the presence of autonomic dysreflexia rather than a primary respiratory or circulatory issue. In autonomic dysreflexia, the primary concern is to remove the noxious stimulus (such as a full bladder, bowel impaction, or tight clothing) that is causing the severe hypertension and bradycardia.

B) Assess below injury for noxious stimuli, anticipate order for hypertensive medication:
The patient’s symptoms are consistent with autonomic dysreflexia, a serious condition that occurs in individuals with a spinal cord injury at or above the T6 level. The body’s autonomic nervous system overreacts to noxious stimuli (such as a distended bladder, bowel impaction, or skin irritation) below the level of injury, leading to a severe hypertensive crisis, bradycardia, and sympathetic hyperactivity. The nurse should immediately assess for and relieve any noxious stimuli below the injury level (e.g., checking for a full bladder, constipation, or tight clothing) and anticipate an order for antihypertensive medications if the blood pressure remains elevated.

C) Administer acetaminophen and initiate intravenous (IV) fluids, anticipate order for atropine:
While pain and discomfort (which can exacerbate autonomic dysreflexia) may need to be managed, acetaminophen is not the priority in this case. The priority is addressing the underlying cause of autonomic dysreflexia, such as relieving noxious stimuli. Additionally, atropine is used for bradycardia, but in autonomic dysreflexia, the bradycardia is secondary to the hypertensive crisis and usually resolves once the noxious stimulus is removed.

D) Lower the head of the bed and apply a cool compress to the forehead:
Although lowering the head of the bed may help reduce intracranial pressure and applying a cool compress may provide comfort, these interventions do not address the underlying cause of the autonomic dysreflexia.

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Correct Answer is C

Explanation

A) Prevent the drainage by applying a tight pressure dressing:
Applying a tight pressure dressing is not the appropriate intervention in this case. The presence of fluid draining from the ear, particularly a yellow stain, could indicate cerebrospinal fluid (CSF) leakage, which is a potential sign of a skull fracture or traumatic brain injury (TBI) involving the base of the skull. Applying a tight pressure dressing could potentially increase pressure or cause further injury.

B) Administer antibiotics due to increased risk of infection:
While there is an increased risk of infection with a CSF leak, antibiotics should not be administered immediately unless there is clear evidence of an infection. The priority action is to identify whether the fluid is CSF, as antibiotics alone will not address the underlying issue of a CSF leak. The nurse should allow the fluid to drain, collect a sample, and notify the healthcare provider for further assessment, which may include imaging or testing for the presence of CSF.

C) Allow fluid to drain from the patient's ear onto gauze and notify the healthcare provider:
The yellow stain around the fluid dripping from the patient's ear suggests the possibility of CSF leakage, a sign of a skull base fracture. CSF leakage may occur after a traumatic brain injury and should be handled carefully. The nurse's priority action is to allow the fluid to drain onto gauze to prevent the buildup of pressure and to prevent further leakage into the ear canal. The nurse should also immediately notify the healthcare provider for further evaluation and management.

D) Hang intravenous (IV) fluids to replace fluids lost and prevent dehydration:
While IV fluids may be necessary in some cases for patients with trauma, the priority in this situation is to identify the source and nature of the drainage. If the fluid is CSF, it may be important to manage the leak appropriately rather than focusing solely on replacing fluids. The nurse should first confirm whether the fluid is CSF and notify the healthcare provider for further assessment and management. Replacing fluids may be necessary, but it is not the immediate priority.

A. Reduce the patient's anxiety B. Assure adequate circulating volume C. Decrease the patient's chest pain D. Maintain adequate oxygenation

Correct Answer is D

Explanation

A) Reduce the patient's anxiety:
While reducing anxiety is an important aspect of patient care, particularly in emergency situations, it is not the priority when life-threatening conditions may be present. Anxiety reduction can be addressed after ensuring that the patient’s more critical physiological needs (such as adequate oxygenation and circulation) are met.

B) Assure adequate circulating volume:
Maintaining adequate circulating volume is important, especially in trauma cases where blood loss is a concern. However, adequate oxygenation takes precedence over circulating volume in this scenario because without proper oxygenation, the patient’s vital organs and tissues may suffer from hypoxia, leading to further complications.

C) Decrease the patient's chest pain:
Chest pain following a motor vehicle accident (MVA) can be a symptom of serious injuries, such as rib fractures, pneumothorax, or even a cardiac contusion. While relieving pain is important for comfort and overall well-being, the priority in the immediate post-trauma phase is to ensure that the patient is receiving adequate oxygen.

D) Maintain adequate oxygenation:
The most critical concern after trauma, especially in a case involving chest impact, is ensuring that the patient is adequately oxygenated. Chest trauma can cause injuries to the lungs or pleural space (e.g., pneumothorax, hemothorax), leading to compromised oxygen exchange. The priority is to assess and maintain the patient's airway, breathing, and oxygenation first.

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The nurse assesses the patient with a spinal cord injury at the level C-7 and finds warm, flushed skin with profuse sweating above the level of injury, and pale, cold skin below the level of injury. The patient is bradycardic, but severely hypertensive. What are the priority nursing interventions?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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