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 A

Explanation

A) Ensure bed alarm is on when leaving patient's room:
The cerebellum plays a critical role in coordinating movement, balance, and motor control. An injury to this area can lead to impaired coordination and dysfunction in balance, making it difficult for the patient to perform the Romberg test (which evaluates balance and proprioception). Given that the patient cannot complete the Romberg test, this suggests the risk of falling or injuring themselves due to impaired balance and coordination. The priority nursing intervention is to ensure safety by using a bed alarm to alert staff if the patient attempts to get out of bed, thereby preventing falls.

B) Vary schedule to prevent memorization and boredom:
While changing the patient's routine may help with engagement, it is not the priority intervention for a patient with cerebellar injury. The primary concern in this situation is safety due to the patient's impaired balance. Addressing issues related to cognitive function or boredom may be important but comes after ensuring the patient’s physical safety.

C) Clarify misinformation and reorient when confused:
Reorientation may be necessary if the patient is confused or disoriented, but this is not the primary concern related to cerebellar injury. The patient’s balance and motor coordination are the most pressing issues. While mental clarity is important, preventing falls due to impaired motor control is the immediate priority.

D) Deep breathing and incentive spirometer education:
Deep breathing exercises and using an incentive spirometer are essential to prevent respiratory complications, particularly after surgery or immobility. However, in this case, the priority concern is the patient's safety related to impaired balance from the cerebellar injury. Respiratory interventions are important but should be addressed after ensuring that the patient is safe from falls and other immediate physical risks.

A. O- B. AB - C. A+ D. A- E. O+

Correct Answer is ["A","D"]

Explanation

A) O- (O negative):
A person with blood type A- can safely receive blood from a universal donor blood type, which is O-. This is because O- has no A, B, or Rh antigens on the surface of its red blood cells, making it compatible with any ABO blood group. The Rh negative status is also compatible, as the recipient is also Rh-negative.

B) AB- (AB negative):
A person with blood type A- cannot receive blood from someone with AB-. This is because the AB- blood type contains both A and B antigens on the surface of red blood cells, which could cause an immune reaction in a person with A- blood, whose immune system will react against the B antigen. Therefore, AB- is not compatible with A- blood.

C) A+ (A positive):
A person with A- blood cannot receive blood from an A+ donor, because the A+ blood contains the Rh positive antigen. If a person with A- blood receives Rh-positive blood, they will form antibodies against the Rh factor, leading to a hemolytic transfusion reaction. Therefore, A+ is not compatible with A- blood.

D) A- (A negative):
A person with A- blood can receive blood from another A- donor, because both share the A antigen and are Rh-negative. This is a perfect match and poses no risk of a transfusion reaction.

E) O+ (O positive):
A person with A- blood cannot receive blood from an O+ donor, because the O+ blood contains the Rh-positive antigen. This could cause an immune reaction in a person with A- blood, leading to the production of anti-Rh antibodies. Therefore, O+ is not compatible with A- blood.

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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

The nurse is caring for a patient diagnosed with an injury to the cerebellum who cannot complete the Romberg Test. Which nursing intervention is priority?

Correct Answer is A

Explanation

The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (SELECT ALL THAT APPLY).

Correct Answer is ["A","D"]

Explanation

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