A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially?

Administer PRN analgesic medication

Lower the head of the bed

Palpate the client's bladder

Administer PRN antihypertensive medication

Answer and Explanation

The Correct Answer is C

A. Analgesics address pain but do not treat the underlying cause of symptoms.
B. Lowering the head of the bed can increase intracranial pressure and worsen hypertension in autonomic dysreflexia.
C. Bladder distention is a common trigger of autonomic dysreflexia; assessing and relieving bladder distention is the priority intervention.
D. Antihypertensive medication may be necessary but only after removing the triggering cause to avoid sudden drops in blood pressure.

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Correct Answer is C

Explanation

A. Assessing pupils is important but should follow spinal precautions to prevent further injury.
B. Glasgow Coma Scale assessment is vital but should not delay spinal immobilization.
C. Immobilizing the cervical spine is a priority to prevent potential spinal cord injury after trauma, especially with head injury and falls. It must be done before moving or further assessment.
D. Gathering history is helpful but is secondary to ensuring patient safety through stabilization.

A. neurogenic shock B. malignant hyperthermia C. neuroleptic malignant syndrome D. tardive dyskinesia

Correct Answer is A

Explanation

A. Neurogenic shock is a common complication of spinal cord injuries above T6, including T4, due to disruption of sympathetic pathways causing hypotension, bradycardia, and vasodilation.
B. Malignant hyperthermia is a rare genetic reaction to certain anesthetics, unrelated to spinal cord injury.
C. Neuroleptic malignant syndrome is a reaction to antipsychotic drugs, not related to spinal cord injury.
D. Tardive dyskinesia is a side effect of long-term antipsychotic use, unrelated to spinal cord injury.

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A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next?

Correct Answer is C

Explanation

The nurse in the emergency department is caring for a client who sustained a spinal cord injury at T4. The nurse should recognize that the client is at risk for developing

Correct Answer is A

Explanation

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?

The nurse is caring for a client with cerebral edema. Which of the following should the nurse recognize as a potential cause of cerebral edema? (Select All that Apply.)

For the patient with a closed head injury from a blunt object, which assessment would the nurse perform as the most reliable clinical indication of a patient's development of an increased intracranial pressure (ICP)?

You keep a postcraniotomy patient's neck in midline position and ensure that there is no excessive hip flexion. The rationale for your action would be that this position:

When planning the care for a patient with an increased intracranial pressure (ICP), which interventions would the nurse integrate to provide the most comfort? Select all that apply. (Select All that Apply.)

The nurse is caring for a client who has cerebral edema. Which of the following therapies should the nurse recognize as appropriate for the treatment of cerebral edema? (Select All that Apply.)

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

A nurse is preparing a client with a possible cervical spine injury for a prescribed CT scan of the head and neck after the client sustained a fall down a stairwell. Which intervention by the nurse is the most important?