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 ["D","E"]

Explanation

Choice A rationale

Weekly appointments to change the catheter are unnecessary unless specifically indicated. Most urinary catheters are changed monthly or as needed based on physician's discretion or complications.

Choice B rationale

Sexual intimacy is possible with an indwelling urinary catheter if handled properly. Providing education on safe practices promotes normalcy and quality of life for the patient.

Choice C rationale

Wearing underwear is recommended to protect the catheter and minimize risk of contamination or accidental dislodgement. This information supports proper hygiene and comfort.

Choice D rationale

Regular emptying of the leg bag every 4 hours or more frequently prevents overfilling, which could lead to backflow and increased risk of urinary tract infections.

Choice E rationale

Foul-smelling, cloudy urine can indicate infection such as a urinary tract infection. Prompt reporting ensures early treatment and prevention of complications.

A. Stabilize the cervical spine until help arrives. B. Control any external bleeding. C. Use the head tilt chin lift method to maintain the airway. D. Do not move the victim from the accident.

Correct Answer is A

Explanation

Choice A rationale

Stabilizing the cervical spine prevents further spinal injury in case of vertebral damage, which is a priority when managing trauma patients until specialized medical care becomes available.

Choice B rationale

While controlling bleeding is essential, it is secondary to stabilizing the cervical spine since the airway and neurological protection take precedence in trauma protocols.

Choice C rationale

The head tilt chin lift method should not be used if cervical spine injury is suspected, as it may exacerbate potential damage to the vertebrae or spinal cord.

Choice D rationale

While not moving the victim is critical, stabilization of the cervical spine is the primary intervention to prevent further injury before emergency assistance arrives.

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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

The nurse is reviewing discharge instructions for a patient with a spinal cord injury to T-10 going home with an indwelling urinary catheter.What would the nurse emphasize about catheter care? (Select All that Apply.)

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

Explanation

A nurse is the first person on the scene of a motor vehicle accident.The victim was the driver and is in the driver's seat unconscious.The driver is breathing, has a pulse, and has minor lacerations on the head and face.What action should the nurse implement first?

Correct Answer is A

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?