A nurse is caring for a patient with a spinal cord injury who is about to be transferred to a wheelchair for physical therapy.
The patient complains of feeling dizzy and is diaphoretic.
What would be the priority nursing action?
Establish IV access and bolus 250 mL of normal saline.
Reschedule the therapy session for later in the day.
Lower the head of the bed and obtain vital signs.
Assess for bladder distention and perform digital disimpaction.
The Correct Answer is C
Choice A rationale
IV fluid bolus may address hypotension but is not the first priority. Symptoms of dizziness and diaphoresis in a spinal cord injury patient suggest autonomic dysreflexia or orthostatic hypotension requiring positional changes first.
Choice B rationale
Rescheduling therapy does not address the acute symptoms the patient is experiencing. Immediate action to manage dizziness and diaphoresis, such as altering body position, is required to stabilize the patient.
Choice C rationale
Lowering the head of the bed counters orthostatic hypotension, a common issue in spinal cord injury patients. Obtaining vital signs identifies the underlying cause and guides further interventions.
Choice D rationale
Bladder distention can trigger autonomic dysreflexia, but without evidence of urinary retention, prioritizing positional adjustments is more urgent to alleviate symptoms of dizziness and stabilize hemodynamics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Subarachnoid hemorrhage is less likely given the sudden decrease in consciousness. This type of injury typically results in severe headache or focal neurological deficits, not rapid mental decline.
Choice B rationale
Diffuse axonal injury usually presents with persistent unconsciousness rather than sudden deterioration. It results from widespread shearing forces and is less likely with the reported history.
Choice C rationale
Epidural hematoma often presents with a lucid interval followed by sudden neurological decline, as described in this case. Rapid accumulation of blood between the dura and skull can compress brain tissue.
Choice D rationale
Subdural hematoma tends to cause gradual neurological deterioration rather than a sudden decrease in Glasgow Coma Scale. This occurs due to slower venous bleeding. .
Correct Answer is B
Explanation
Choice A rationale
Susceptible host pertains to the individual's vulnerability to an infectious agent, but handwashing targets the mode of transmission rather than addressing susceptibility or the infectious agent directly.
Choice B rationale
Handwashing interrupts the mode of transmission, preventing pathogens from reaching a portal of entry. This action disrupts the chain of infection and reduces pathogen spread effectively.
Choice C rationale
The infectious agent and reservoir focus on pathogen origination rather than its transfer. Handwashing reduces spread but does not directly address pathogen survival within reservoirs.
Choice D rationale
Portal of exit involves the pathogen leaving the host's body, not its transfer. Handwashing reduces pathogen transmission, specifically addressing its ability to reach a new host.
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