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 A

Explanation

A. Mannitol is an osmotic diuretic that pulls fluid from brain tissue into the vascular space, which can lead to fluid overload and pulmonary edema. Crackles on auscultation may indicate this complication and should be assessed.
B. While peripheral edema may occur with fluid overload, crackles are a more immediate and concerning sign of pulmonary congestion related to mannitol.
C. An increase in Glasgow Coma Scale score indicates improvement in neurologic function, not a complication.
D. Increased urine output is an expected effect of mannitol; it helps reduce ICP by promoting diuresis.

A. Provide the patient a quiet and calm environment.. B. Minimize procedures that potentially produce agitation. C. Facilitate an increased number of family visits to the patient. D. Encourage the patient's family to increase patient interactions. E. Observe the patient for signs of agitation or irritation and intervene. F. Observe the patient for signs of agitation or irritation and intervene.

Correct Answer is ["A","B","E"]

Explanation

A quiet and calm environment helps reduce stimuli that can increase ICP and cause discomfort.
B. Minimizing procedures that cause agitation prevents spikes in ICP and patient distress.
C. Too many or prolonged family visits can overstimulate the patient, increasing ICP and discomfort.
D. Excessive interaction may overstimulate the patient; interaction should be limited based on tolerance.
E. Early identification and intervention for agitation help maintain stable ICP and patient comfort.

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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

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?

Correct Answer is A

Explanation

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.)

Correct Answer is ["A","B","E"]

Explanation

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:

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