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 C

Explanation

Choice A reason:

A decrease in specific gravity is not the primary therapeutic outcome of desmopressin in the treatment of diabetes insipidus. Desmopressin works by increasing water reabsorption in the kidneys, which leads to a decrease in urine output and an increase in urine concentration, reflected by an increase, not a decrease, in specific gravity.

Choice B reason:

A decrease in the level of consciousness is not an intended therapeutic outcome and would be concerning if observed. Desmopressin aims to control symptoms of diabetes insipidus, not alter the patient’s mental status.

Choice C reason:

A decrease in urine output is the primary therapeutic outcome of desmopressin in a patient with diabetes insipidus. Desmopressin mimics the action of antidiuretic hormone (ADH), leading to increased water reabsorption in the kidneys and reduced urine volume.

Choice D reason:

Desmopressin does not primarily aim to decrease blood pressure. Its main effect is on water reabsorption in the kidneys, thereby reducing urine output. While it can have some impact on blood pressure, this is not its primary therapeutic outcome.

A. Sodium level. B. Fluid intake. C. Heart rate. D. Urine output.

Correct Answer is D

Explanation

Choice A reason:

Monitoring sodium levels is important when administering mannitol, but it is not the primary indicator of the drug's effectiveness. Mannitol is an osmotic diuretic used to reduce intracranial pressure, and its effectiveness is better assessed by other means.

Choice B reason:

Fluid intake is important to monitor to ensure proper hydration status, but it does not directly indicate the effectiveness of mannitol. The primary focus should be on the patient's output to assess the diuretic effect.

Choice C reason:

Heart rate monitoring is essential for overall patient care but does not directly indicate the effectiveness of mannitol. Changes in heart rate can occur due to various factors and are not specific to mannitol's action.

Choice D reason:

Urine output is the most direct measure of mannitol's effectiveness. As an osmotic diuretic, mannitol promotes diuresis, and increased urine output indicates that the drug is effectively reducing intracranial pressure.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with a head injury who has developed diabetes insipidus and is receiving desmopressin. The nurse understands the therapeutic outcome is a decrease in:

Correct Answer is C

Explanation

To evaluate the effectiveness of mannitol, the nurse should monitor:

Correct Answer is D

Explanation

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