A client with a history of a T2 spinal cord injury tells the nurse, "I feel awful today. My head is throbbing and I feel sick to my stomach." Which action should the nurse take first?
Assess for a fecal impaction
Give the prescribed antiemetic
Check the blood pressure
Notify the health care provider
The Correct Answer is C
A. Assess for a fecal impaction: Fecal impaction can trigger autonomic dysreflexia in clients with spinal cord injuries, but assessing it is not the first action. Immediate evaluation of vital signs is essential to determine if a hypertensive crisis is occurring. Delaying this could put the client at risk for serious complications.
B. Give the prescribed antiemetic: Administering an antiemetic addresses nausea but does not treat the potentially life-threatening cause. In spinal cord injury, symptoms like headache and nausea may signal autonomic dysreflexia. Treating symptoms without assessing for the underlying cause can be dangerous.
C. Check the blood pressure: Clients with T6 or higher spinal cord injuries are at risk for autonomic dysreflexia, which can present with sudden hypertension, headache, and nausea. Checking blood pressure first identifies a potentially emergent situation. Rapid recognition allows for timely interventions to prevent stroke or other complications.
D. Notify the health care provider: Notification is important but comes after assessing the client’s blood pressure and identifying a potential emergency. Immediate action depends on objective data rather than only reporting symptoms. This ensures the provider receives accurate and timely information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Salt-wasting syndrome and autonomic dysreflexia: Salt-wasting syndrome is not a common long-term complication of spinal cord injury. Autonomic dysreflexia is a risk, but the combination is inaccurate.
B. Autonomic dysreflexia and orthostatic hypotension: Clients with spinal cord injuries, especially above T6, are at risk for autonomic dysreflexia due to exaggerated sympathetic responses. They also commonly experience orthostatic hypotension because of impaired sympathetic tone. Both conditions require ongoing monitoring and preventive strategies.
C. Deep vein thrombosis and increased intracranial pressure: DVT is a potential risk, but increased intracranial pressure is not typically associated with chronic spinal cord injury. This combination does not reflect the most relevant long-term complications.
D. Orthostatic hypertension and deep vein thrombosis: Orthostatic hypotension, not hypertension, is a common complication in spinal cord injury. DVT is a risk, but the incorrect term for blood pressure regulation makes this inaccurate.
Correct Answer is A
Explanation
A. the depth and duration of unresponsiveness and altered LOC: The severity and length of impaired consciousness are directly correlated with brain injury extent and recovery potential. Longer and deeper unresponsiveness generally predicts poorer outcomes. This factor is the most reliable indicator of rehabilitation potential.
B. the size of the subdural hematoma: Hematoma size can influence prognosis, but recovery also depends on the brain’s functional response and overall injury severity. It is not as predictive as level of consciousness.
C. the skill and competency of the nursing, and medical staff: Skilled care improves outcomes and prevents complications, but it cannot fully predict the client’s inherent neurologic recovery potential.
D. recognizing and treating complications early: Early intervention is critical for preventing secondary injury but is less predictive of long-term rehabilitation potential than the initial depth and duration of altered LOC.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.