A nurse assesses a patient with a spinal cord injury at level T5. The patient's blood pressure is 184/95 mm Hg, and the patient presents with a flushed face and blurred vision. What action would the nurse take first in response to this complication?

Palpate the bladder for distention.

Initiate oxygen via a nasal cannula.

Place the patient in a supine position.

Administer a prescribed beta-blocker.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Palpating the bladder for distention is the first action the nurse should take. The patient's symptoms suggest autonomic dysreflexia, a condition that can be triggered by bladder distention. Relieving the distention can help resolve the hypertensive crisis.

Choice B reason:

Initiating oxygen via a nasal cannula may be necessary if the patient is experiencing respiratory distress, but it is not the primary intervention for autonomic dysreflexia. The focus should be on identifying and resolving the triggering cause.

Choice C reason:

Placing the patient in a supine position is contraindicated in autonomic dysreflexia as it can worsen the condition by further increasing blood pressure. The patient should be positioned upright if tolerated.

Choice D reason:

Administering a prescribed beta-blocker may help lower blood pressure, but it is not the first action. The underlying cause of autonomic dysreflexia must be addressed to prevent recurrence.

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Correct Answer is A

Explanation

Choice A reason:

The extent of impairment following a spinal cord injury cannot be determined until any secondary injury to the cord has resolved. Secondary injury, such as inflammation and swelling, can worsen the initial damage and impact the long-term prognosis.

Choice B reason:

An MRI can reveal the extent of cord damage but does not provide a complete picture of the potential functional outcomes. The full extent of impairment cannot be determined solely by imaging.

Choice C reason:

Stating that the patient will have normal function when spinal shock resolves and the reflex arc returns is misleading and overly optimistic. Not all patients will regain normal function after a spinal cord injury, and outcomes vary.

Choice D reason:

While rehabilitation plays a crucial role in recovery, stating that it will be years before impairment can be determined is not entirely accurate. Functional outcomes can often be assessed sooner as the initial recovery phase progresses.

A. Soak the pin sites with alcohol pads B. Remove the vest when bathing the patient C. Assess the chest and back for skin breakdown D. Assess pin sites frequently for signs of infection E. Tape a halo wrench to the vest for emergencies

Correct Answer is ["C","D","E"]

Explanation

Choice A reason:

Soaking the pin sites with alcohol pads is not recommended as it can dry out the skin and increase the risk of infection. Pin site care typically involves using saline or other recommended solutions to clean the area gently.

Choice B reason:

Removing the vest when bathing the patient is not recommended. The vest provides stability and support for the spinal fracture, and removing it can compromise the patient's safety. Alternative methods should be used to maintain hygiene without removing the vest.

Choice C reason:

Assessing the chest and back for skin breakdown is crucial in patients with a halo device to prevent pressure ulcers and other skin issues. Regular assessment helps identify any potential problems early.

Choice D reason:

Assessing pin sites frequently for signs of infection is essential to prevent complications. Infection at the pin sites can lead to serious issues, and frequent monitoring ensures any signs of infection are caught and treated promptly.

Choice E reason:

Taping a halo wrench to the vest is important for emergencies. The wrench is necessary to quickly remove the halo device if needed in an emergency situation, such as if the patient requires resuscitation.

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A nurse assesses a patient with a spinal cord injury at level T5. The patient's blood pressure is 184/95 mm Hg, and the patient presents with a flushed face and blurred vision. What action would the nurse take first in response to this complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Immediately following a spinal cord injury, a patient asks about the extent of impairment that will result from the injury. The best response by the nurse is:

Correct Answer is A

Explanation

The nurse is preparing to care for a patient with a spinal fracture who has a halo device in place. The nurse plans to implement the following orders:

Correct Answer is ["C","D","E"]

Explanation

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