A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include BP of 220/110 mm Hg, with an apical heart rate of 54/min. Which of the following actions should the nurse take first?
Notify the provider.
Sit the client upright in bed.
Check the client’s urinary catheter for blockage.
Administer antihypertensive medication.
The Correct Answer is B
These manifestations indicate autonomic dysreflexia, a medical emergency in patients with spinal cord injuries at or above T6. The first priority is to sit the client upright to lower blood pressure and reduce the risk of stroke. Immediate interventions focus on relieving the precipitating stimulus while monitoring cardiovascular status.
Rationale for correct answer:
2. Sit the client upright in bed. Elevating the head of the bed promotes venous pooling in the lower extremities, reducing systemic blood pressure and mitigating the acute risks of hypertensive crisis. This is the fastest and most effective initial intervention while assessing the cause of the episode.
Rationale for incorrect answers:
1. Notify the provider. Important, but provider notification should occur after immediate safety measures are initiated. Delaying action could increase risk of stroke or seizure.
3. Check the client’s urinary catheter for blockage. Bladder distention is a common trigger, but assessment of the cause comes after immediate BP control.
4. Administer antihypertensive medication. Medication may be needed if symptoms persist, but nonpharmacologic interventions (sitting upright, removing stimuli) are first-line emergency care.
Take-home points:
- Autonomic dysreflexia is a life-threatening emergency marked by severe hypertension, headache, and diaphoresis.
- Immediate priority is to sit the patient upright to reduce blood pressure.
- Identify and remove the triggering stimulus promptly to prevent complications such as stroke or seizure.
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Related Questions
Correct Answer is D
Explanation
A C4 spinal cord injury can result in paralysis of the diaphragm and intercostal muscles, which significantly compromises respiratory function. The greatest risk is respiratory compromise, which can lead to hypoventilation, hypoxia, and potential respiratory failure. Maintaining airway patency and monitoring respiratory status are top priorities in acute care.
Rationale for correct answer:
4. Respiratory compromise. C4 injuries impair diaphragmatic and accessory muscle function, making the patient highly dependent on ventilatory support. Early recognition of respiratory difficulty and timely interventions are critical to prevent life-threatening complications.
Rationale for incorrect answers:
1. Neurogenic shock. While possible in high-level SCI, neurogenic shock typically occurs acutely and is managed; it is not as immediately life-threatening as respiratory compromise in C4 injuries.
2. Paralytic ileus. Paralytic ileus is more common in thoracic and lumbar injuries; it is secondary in priority to airway and breathing concerns.
3. Stress ulcer. Stress ulcers are a potential complication but develop later and are not an immediate threat to life compared with respiratory failure.
Take-home points:
- C4 SCI patients are at highest risk for respiratory compromise due to diaphragmatic paralysis.
- Continuous monitoring of oxygenation, ventilation, and airway is essential.
- Early intervention with mechanical ventilation or suctioning may be required to maintain life-sustaining respiration.
Correct Answer is ["B","C","D","E"]
Explanation
A C6 spinal cord injury allows partial use of the shoulders and upper arms as well as wrist extension. With adaptive devices and rehabilitation, patients can achieve independence in many activities of daily living (ADLs) but cannot ambulate independently because leg function is absent.
Rationale for correct answers:
2. Feed self with hand devices. Patients at C6 can use adaptive hand devices to feed themselves because they retain shoulder movement and partial wrist control.
3. Assist with transfer activities. With training, patients can participate in transfers using sliding boards or mechanical lifts.
4. Drive adapted van from wheelchair. Adaptive driving controls make this possible with upper extremity strength and wrist function.
5. Push a wheelchair on a flat surface. C6 patients have enough arm and wrist strength to propel a manual wheelchair on level ground.
Rationale for incorrect answer:
1. Stand erect with leg brace. This requires lower extremity motor function, which is absent at the C6 injury level. Standing with braces is possible only with lower thoracic or lumbar injuries, not cervical.
Take-home points:
- C6 injury patients have functional use of shoulders, arms, and wrists but no voluntary leg function.
- They can achieve independence in feeding, transfers, mobility, and some driving with adaptive equipment.
- Walking or standing independently is not realistic at this level of injury.
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