The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

Elevate the head of the bed, loosen clothing, and check the urinary catheter for obstruction

Elevate the head of the bed and apply a cool compress to the forehead

Place in Semi-Fowler's position and establish IV access

Establish IV access, apply 2 liters of nasal oxygen, and contact the health care provider

Answer and Explanation

The Correct Answer is A

A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.

B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.

C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.

D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.

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Correct Answer is C

Explanation

A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.

B. Documenting without intervention could lead to worsening of the patient's condition.

C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.

D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.

A. Severe headache B. Generalized weakness C. Gradual blurry vision D. Chest pain

Correct Answer is A

Explanation

A. A severe headache, often described as a "thunderclap" headache or the worst headache of the patient’s life, is a classic symptom of subarachnoid hemorrhage due to irritation of the meninges and increased intracranial pressure.

B. Generalized weakness may occur in some neurological conditions but is not a hallmark symptom of subarachnoid hemorrhage.

C. Gradual blurry vision is more associated with conditions like increased intracranial pressure or other eye-related issues rather than acute subarachnoid hemorrhage.

D. Chest pain is not typically associated with subarachnoid hemorrhage; it may indicate other conditions such as myocardial infarction or pulmonary issues.

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The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient in the ICU with a diagnosis of acute closed head injury whose intracranial pressure (ICP) is 30mmHg. What is the priority action by the nurse?

Correct Answer is C

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Correct Answer is A

Explanation

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