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 ["2525"]
Explanation
Step 1 is calculate intake from lactated Ringer’s: 150 mL/hr × 9 hrs = 1350 mL.
Step 2 is calculate cefazolin intake: 100 mL × 1 dose = 100 mL.
Step 3 is calculate intake from two units of packed RBCs: 275 mL + 250 mL = 525 mL.
Step 4 is calculate intake from two IV boluses: 250 mL × 2 = 500 mL.
Step 5 is calculate intake from ranitidine infusion: 50 mL × 1 dose = 50 mL.
Step 6 is calculate total intake: 1350 mL + 100 mL + 525 mL + 500 mL + 50 mL = 2525 mL. Final calculated intake is 2525 mL.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Elevating the head 30-45 degrees aids in venous drainage and reduces intracranial pressure. It also prevents cerebral edema by improving cerebrospinal fluid outflow without compromising cerebral perfusion.
Choice B rationale
Serial neurological assessments help monitor for changes in intracranial pressure, enabling early intervention. They ensure timely recognition of symptoms indicating worsening pressure or neurological deterioration.
Choice C rationale
Frequent suctioning increases intracranial pressure due to stimulation of the vagus nerve, leading to coughing or gagging. It can also induce hypoxia, further exacerbating intracranial pressure.
Choice D rationale
Administering sedatives and pain medications reduces cerebral metabolic rate and sympathetic stimulation, which in turn prevents spikes in intracranial pressure. It also helps prevent agitation and discomfort in the patient.
Choice E rationale
Stimulating the patient with TV, music, lights, and family increases sensory input, which can elevate intracranial pressure. Overstimulation can cause agitation, raising intracranial pressure further.
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