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 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.

A. Review the safety data sheet online for products with bleach. B. Continue irrigating eyes with saline until pain-free, then check pH of both eyes. C. Contact the physician for miotic ophthalmic drops for pain control. D. Assess visual acuity of both eyes and check vital signs.

Correct Answer is B

Explanation

Choice A rationale

Reviewing the safety data sheet does not directly alleviate the immediate chemical injury or prevent further damage. Immediate irrigation of the eyes is the priority after chemical exposure to minimize damage to the ocular surface.

Choice B rationale

Continuous irrigation removes chemical agents from the eyes and prevents further damage. Ensuring a pain-free state and checking pH confirm the removal of irritants, essential for preventing deeper eye tissue damage.

Choice C rationale

Miotic drops reduce intraocular pressure but do not address acute chemical injury. Pain relief is secondary to irrigating and neutralizing pH, which directly prevents ongoing tissue damage and irritation.

Choice D rationale

Assessing visual acuity and vital signs is important but secondary to preventing further chemical penetration. Immediate irrigation prevents damage progression and is prioritized over assessments during the acute phase of exposure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which behaviors by the patient diagnosed with a chronic head injury would the nurse expect to find?

Correct Answer is C

Explanation

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?