A client with a C-7 spinal cord injury (SCI) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

While caring for a client with a cervical spine injury, which assessment finding should the nurse report to the healthcare provider immediately?

A client who sustained an L-1 spinal cord injury six months ago that resulted in paraplegia is now experiencing spastic muscle movements in the lower extremities. Which intervention should the nurse implement?

A client who sustained a head injury is alert and oriented to person, place, time, and situation, moves all extremities on command, has equal muscle strength bilaterally, and pupils are reactive to light. Which action should the nurse implement next?

Patient Data

The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment.
Which assessment(s) should the nurse conduct? Select all that apply.

A client was admitted 36 hours ago for a head injury that occurred as the result of a motorcycle accident. In the last four hours, the client's urine output has increased to over 200 mL/hour. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?

After six days on a mechanical ventilator, a client is extubated and placed on 40% oxygen via face mask. The client is awake and cooperative, but reports having a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if airway is restricted. Which intervention is most important for the nurse to implement?

After two minutes of cardiopulmonary resuscitation, the client's electrocardiogram (ECG) displays third degree heart block with no palpable pulse. Which intervention should the nurse implement?

An adult client is being admitted to the coronary care unit with a possible myocardial infarction (MI). The client reports feeling like they are going to "pass out." The cardiac monitor displays the rhythm shown. The client's respiratory rate is 12 to 16 breaths/minute and blood pressure is 78/52 mm Hg. The nurse auscultates clear breath sounds bilaterally and the skin is pale and diaphoretic. After administering oxygen, which action should the nurse prepare to perform?

A week after a client suffered a high thoracic spinal cord injury in a motor vehicle collision, the blood pressure suddenly rises to 196/126 mm Hg. Which physiological sign(s) should the nurse identify that the client is exhibiting autonomic dysreflexia? select all that apply.

A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the client for?