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.

Answer and Explanation

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. .

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Correct Answer is A

Explanation

Choice A rationale

Vigorous coughing or nose blowing increases pressure in the middle ear, potentially dislodging the stapes prosthesis, interfering with healing, and increasing risk of complications like vertigo or auditory damage.

Choice B rationale

Packing with dry dressing is contraindicated because it may trap moisture and increase infection risk. If drainage occurs, sterile measures are taken to assess and manage infection without creating ideal conditions for pathogens.

Choice C rationale

Irrigation of the ear canal risks introducing pathogens or disrupting the surgical area. Post-surgery, maintaining a dry environment helps reduce infection and promote proper healing.

Choice D rationale

Though bedrest may be recommended initially, prolonged immobility isn't essential unless specific complications arise. Movement minimizes risks of clot formation and encourages circulation, aiding recovery.

A. Oxygen at 6 liters per minute via nasal cannula. B. Ipratropium via metered dose inhaler. C. Propranolol by oral administration. D. An organic herbal supplement.

Correct Answer is B

Explanation

Choice A rationale

Administering oxygen at 6 liters per minute via nasal cannula risks hypercapnia in a client with emphysema due to impaired CO2 elimination. Oxygen should be titrated to maintain safe saturation levels, usually 88–92%.

Choice B rationale

Ipratropium is a bronchodilator that safely alleviates airway constriction in emphysema without systemic cardiovascular effects, making it suitable for a client with coronary artery disease and chronic obstructive pulmonary conditions.

Choice C rationale

Propranolol is contraindicated in emphysema due to its beta-blocking effects, which may exacerbate bronchoconstriction and reduce respiratory function, posing a significant risk to the client’s health.

Choice D rationale

Organic herbal supplements lack evidence-based safety and efficacy, especially in complex medical conditions like coronary artery disease and emphysema. They can also interact adversely with prescribed medications.

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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?

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Naxlex Comprehensive Predictor Exams

A client has had a stapedectomy for otosclerosis 24 hours ago.What must the nurse teach the client about post-operative care?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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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?