The nurse is caring for a patient with a spinal cord injury at the level of C-7. The patient is having a severe headache, hypertension, bradycardia, diaphoresis, and flushing of the face with pale, cold skin below the level of the injury.
What are the priority nursing interventions?
Elevate the head of the bed, loosen clothing, check the urinary catheter for obstruction.
Elevate the head of the bed and apply a cool compress to the forehead.
Establish IV access, apply 2L of oxygen via nasal cannula, notify provider.
Place in supine position and establish IV access for medication administration.
The Correct Answer is A
Choice A rationale
Elevating the head of the bed reduces blood pressure and intracranial pressure. Loosening restrictive clothing addresses triggers of autonomic dysreflexia, while checking the catheter resolves bladder-related stimulus for this medical emergency.
Choice B rationale
Although elevating the head of the bed is correct, applying a cool compress doesn't address the root cause of autonomic dysreflexia. The compress offers temporary relief without resolving the underlying triggers.
Choice C rationale
IV access and oxygen application are secondary interventions. The priority is resolving triggers like bladder distension or tight clothing to prevent further autonomic dysreflexia complications.
Choice D rationale
Placing the patient in a supine position can exacerbate hypertension and intracranial pressure. This positioning fails to address triggers of autonomic dysreflexia and is contraindicated in this condition. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Chronic head injuries can impair judgment, leading to non-compliance with care plans due to reduced awareness and impulse control. However, non-compliance alone is not a definitive behavioral characteristic of chronic head injury.
Choice B rationale
Rapid engagement in cognitively demanding tasks like chess within a week suggests intact neurological and cognitive function, which contradicts the expected deficits in chronic head injury patients.
Choice C rationale
Chronic head injuries commonly affect the frontal lobe, impairing executive functions such as planning, organizing, and controlling thoughts and behaviors. These deficits result from damage to neural pathways crucial for these cognitive tasks.
Choice D rationale
The ability to process multiple pieces of information simultaneously requires intact cognitive functioning, typically disrupted in chronic head injuries due to neuronal damage, particularly in the prefrontal cortex.
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.
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