A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for?

Choice A reason: The electrician who suffered external burn injuries a month ago is stable enough to be concerned with discharge plans. This indicates that his burns have been managed and he is in a phase of recovery where he is preparing for discharge. Although his request is important, it is not an immediate priority compared to more acute conditions.

Choice B reason: The older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body is in a critical condition and needs continuous monitoring, especially with high fluid administration. However, their condition is currently being managed with IV fluids. While this client requires close observation, there is no immediate indication of a life-threatening change that demands immediate intervention compared to the firefighter's situation.

Choice C reason: The adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain is also in need of pain management and ongoing care. However, pain, while significant and requiring treatment, does not take precedence over the potential airway compromise and respiratory distress posed by smoke inhalation and facial burns in the firefighter.

Choice D reason: The firefighter with smoke inhalation and facial burns who has just arrived on the unit must be assessed first due to the immediate risk of airway compromise and respiratory distress. Smoke inhalation can lead to rapid swelling of the airways, making it a critical emergency. Facial burns also increase the risk of airway obstruction. Prompt assessment and intervention are essential to ensure the firefighter's airway remains patent and to provide necessary respiratory support.

Choice A reason: Rechecking all of the patient's vital signs is a good practice, but it is not the priority action in this scenario. The patient's symptoms indicate a potential case of autonomic dysreflexia, a life-threatening condition that requires immediate action to reduce blood pressure and address the cause. Rechecking vital signs alone will not resolve the underlying issue.

Choice B reason: Elevating the patient's knees and lowering the head of the bed is not an appropriate action in this situation. This position could potentially increase intracranial pressure and exacerbate the patient's condition. The focus should be on measures that will help lower the blood pressure and alleviate the symptoms of autonomic dysreflexia.

Choice C reason: The priority action is to elevate the head of the bed immediately and notify the provider. Elevating the head of the bed helps to decrease blood pressure and improve venous return. Promptly notifying the provider ensures that the patient receives timely medical intervention to address the underlying cause of autonomic dysreflexia, which is critical for preventing further complications.

Choice D reason: Administering PRN Tylenol for the patient's headache is not the priority in this situation. While pain management is important, the patient's symptoms suggest a more severe condition (autonomic dysreflexia) that requires immediate attention to lower blood pressure and address the root cause. Pain medication alone will not resolve the underlying issue and could delay necessary interventions.