A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The BP is significantly elevated to 190/100. The first action by the nurse is to:

Elevate the head of the bed immediately and notify the provider

Administer PRN tylenol for the patient's headache

Recheck all of the patient's vital signs

Elevate the patient's knees and lower the head of the bed

Answer and Explanation

The Correct Answer is A

Choice A reason:

Elevating the head of the bed and notifying the provider is the correct initial action when a patient with a spinal cord lesion at T4 experiences a significantly elevated blood pressure (190/100), headache, and flushing. These symptoms suggest autonomic dysreflexia, a potentially life-threatening condition that requires immediate intervention. Elevating the head of the bed helps to lower blood pressure, and notifying the provider ensures that further medical treatment can be administered promptly.

Choice B reason:

Administering PRN Tylenol for the patient's headache is not the appropriate first action in this scenario. While Tylenol may help with the headache, it does not address the underlying cause of the elevated blood pressure and autonomic dysreflexia. Immediate intervention to lower blood pressure is critical to prevent complications.

Choice C reason:

Rechecking all of the patient's vital signs is important but not the priority action in this situation. The nurse should first take measures to lower the blood pressure and address the symptoms of autonomic dysreflexia by elevating the head of the bed and notifying the provider. Monitoring vital signs can be done concurrently, but it should not delay the immediate intervention required.

Choice D reason:

Elevating the patient's knees and lowering the head of the bed is contraindicated in this situation. Lowering the head of the bed can further increase intracranial pressure and exacerbate symptoms of autonomic dysreflexia. The proper position to help reduce blood pressure is to elevate the head of the bed.

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Correct Answer is B

Explanation

Choice A reason:

A 72-year-old client with a brain tumor, GCS of 5, and decerebrate posturing may not be an ideal candidate for organ donation due to age and underlying cancer, which can affect organ viability.

Choice B reason:

A 24-year-old client after a motor vehicle accident with a GCS of 3 and no activity on electroencephalogram is a prime candidate for organ donation. The lack of brain activity indicates brain death, and the patient's young age and otherwise healthy organs make them suitable for transplantation.

Choice C reason:

A 68-year-old male with a massive stroke and GCS of 6 has significant neurological impairment but is not necessarily brain dead. Further evaluation would be required, but this patient may not meet the criteria for brain death necessary for organ donation.

Choice D reason:

A 50-year-old female with a GCS of 12 after surgical evacuation of an epidural hematoma is not an ideal candidate for organ donation at this time as they have a higher level of consciousness and potential for recovery.

A. Obtain an order for a chest x-ray. B. Increase the PEEP. C. Perform endotracheal suctioning. D. Reposition the patient.

Correct Answer is C

Explanation

Choice A reason:

While obtaining a chest x-ray can help assess the patient's condition, it is not the immediate action needed in this situation. The patient's drop in SaO2 and agitation indicate an acute issue that needs to be addressed promptly.

Choice B reason:

Increasing the PEEP might help improve oxygenation, but it is not the first action to take. The presence of coarse crackles suggests the need to clear secretions first before adjusting ventilator settings.

Choice C reason:

Performing endotracheal suctioning is the appropriate immediate action. Coarse crackles indicate the presence of secretions in the airway, which can impair ventilation and oxygenation. Suctioning helps clear the airway and improve the patient's SaO2 levels.

Choice D reason:

Repositioning the patient can help with ventilation and comfort but is not the priority action when there are indications of airway obstruction. Clearing the airway through suctioning takes precedence in this scenario.

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A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The BP is significantly elevated to 190/100. The first action by the nurse is to:

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Naxlex Comprehensive Predictor Exams

A charge nurse is reviewing the status of patients in the critical care unit. Which patient should the charge nurse notify the organ procurement team to evaluate for possible organ donation?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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