A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea. The nurse’s first priority is to:
call the physician
check the patient’s temperature
take the patient’s blood pressure
elevate the head of the bed to 90 degrees
The Correct Answer is C
In a patient with a spinal cord injury at or above T6, sudden severe headache and nausea are hallmark signs of autonomic dysreflexia, a life-threatening emergency caused by an exaggerated sympathetic response to noxious stimuli (such as bladder distention, fecal impaction, or skin irritation). The nurse’s first action is to check the patient’s blood pressure to confirm the diagnosis, since autonomic dysreflexia results in severe hypertension.
Rationale for correct answer:
3. Take the patient’s blood pressure. Confirms whether the symptoms are due to autonomic dysreflexia by detecting dangerous hypertension, which requires immediate intervention.
Rationale for incorrect answers:
1. Call the physician. Contacting the provider is important but not the first action—the nurse must first assess the patient’s BP to confirm the condition.
2. Check the patient’s temperature. Headache and nausea are not early signs of infection in this context; checking temperature delays recognition of a true emergency.
4. Elevate the head of the bed to 90 degrees. This is an essential intervention to lower blood pressure, but assessment (BP check) must be done first to confirm the cause of symptoms.
Take-home points:
- Autonomic dysreflexia presents with severe headache, nausea, flushing, bradycardia, and hypertension in SCI patients at or above T6.
- First priority is to check blood pressure to confirm the condition.
- Once confirmed, the nurse elevates the HOB, removes noxious stimuli, and notifies the physician.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Muscle relaxants can have significant side effects in patients with acute cervical spinal cord injury, including respiratory depression, hypotension, and sedation. In the early post-injury phase, careful consideration is needed because these medications may exacerbate already compromised respiratory function. The nurse should clarify the order to ensure it is appropriate for the patient’s current neurological and respiratory status.
Rationale for correct answer:
4. Muscle relaxants. The client will still be in spinal shock 24 hr following the injury. The client will not
experience muscle spasms until after the spinal shock has resolved, making muscle relaxants
unnecessary at this time.
Rationale for incorrect answers:
1. Glucocorticoids. Glucocorticoids are appropriate medications to administer at this time as they are not universally contraindicated.
2. Plasma expanders. These are standard in managing hypotension or neurogenic shock and are appropriate in acute SCI care.
3. H2 antagonists. Used prophylactically to prevent stress ulcers, which are common in immobile patients, and are safe for acute SCI management.
Take-home points:
- Muscle relaxants may impair respiratory function in cervical SCI and require careful evaluation before use.
- Clarify medication orders to ensure safety and appropriateness based on the patient’s condition.
- Standard medications like plasma expanders and H2 antagonists are generally safe and part of routine acute SCI care.
Correct Answer is A
Explanation
A condom catheter is an appropriate bladder management method for a male patient with a cervical spinal cord injury who has some voluntary voiding or reflex bladder emptying. This method is noninvasive, reduces the risk of urethral trauma, and allows for continuous urinary drainage without the complications of an indwelling catheter. Proper placement and hygiene are essential to prevent skin breakdown and infection.
Rationale for correct answer:
1. Condom catheter. This method provides a safe and convenient option for male patients with SCI who can void reflexively or partially, reducing the risk of urinary tract infections compared with indwelling catheters. It is less invasive and allows the patient to maintain some independence in urinary management.
Rationale for incorrect answers:
2. Intermittent urinary catheterization. While generally preferred for long-term bladder management, it may not be needed if the patient can void adequately with a condom catheter.
3. Crede’s method. Manual compression of the bladder is less safe and can increase the risk of urethral trauma or reflux, particularly in high-level injuries.
4. Indwelling urinary catheter. Continuous catheterization carries a higher risk of infection and urethral injury, making it less desirable for long-term use.
Take-home points:
- A condom catheter is suitable for male SCI patients with reflex or partial voiding.
- Proper placement and hygiene are essential to prevent skin breakdown and infection.
- More invasive methods like indwelling catheters or Crede’s method are reserved for patients who cannot void adequately.
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