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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Brown-Sequard injury results in ipsilateral motor function loss due to corticospinal tract damage and contralateral pain/temperature loss from spinothalamic tract disruption, characteristic of this hemisection spinal cord injury.

Choice B rationale

Central cord injury affects cervical spine and hand function but does not exhibit hemisection symptoms like ipsilateral motor loss or contralateral sensory loss. Symptoms vary and commonly include upper limb weakness.

Choice C rationale

Posterior cord injury primarily impacts dorsal column function, resulting in loss of proprioception and vibration sense. Motor and pain/temperature functions are preserved, unlike in Brown-Sequard injury.

Choice D rationale

Anterior cord injury involves ischemic damage to the anterior spinal artery, leading to motor paralysis and pain/temperature loss bilaterally, not ipsilateral and contralateral as described in the question.

A. The patient will recall events from childhood. B. The patient will return to work as a corporate attorney. C. The patient will actively participate in the rehabilitation process as appropriate. D. The patient will demonstrate improved motor coordination within two weeks.

Correct Answer is C

Explanation

Choice A rationale

Childhood memory recall reflects cognitive functioning but is unrelated to the patient's rehabilitation involvement, which focuses on regaining lost functional capacities following injury. Such a goal lacks immediate functional relevance.

Choice B rationale

Returning to work as a corporate attorney may be an eventual aim but depends on higher cognitive recovery levels and is too specific. Early rehabilitation outcomes focus on participation in the recovery process.

Choice C rationale

Active participation indicates readiness and willingness to engage in therapies essential for regaining lost functions. It aligns with goals for a transition from acute care to rehabilitation emphasizing functional improvement.

Choice D rationale

Motor coordination improvements require therapy timelines extending beyond two weeks. Such a rigid short-term goal undermines individualized rehabilitation focusing on measurable progress over more realistic durations.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is caring for a patient who had a serious head injury.The patient has recovered enough to be transferred to a rehabilitation facility.Which of the following rehabilitation goals would be most appropriate for the patient?

Correct Answer is C

Explanation

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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?