The nurse assesses a patient with a recent spinal cord injury at the level of thoracic 5 vertebrae. The patient's blood pressure is 184/95 mm Hg, has a flushed face and blurred vision. What priority action would the nurse complete first?

Notify the health care provider of the patient's status.

Assess patient for tight clothing around the waist or a full bladder.

Review the medication administration record for an antihypertensive order.

Initiate oxygen via a nasal cannula and elevate patient's legs.

Answer and Explanation

The Correct Answer is B

Choice A reason: Notifying the health care provider of the patient's status is an important action, but not the first priority. The nurse should first assess the patient for any possible triggers of the autonomic dysreflexia, which is a life-threatening condition that occurs in patients with spinal cord injury above the level of T6. It is characterized by a sudden and severe increase in blood pressure, flushing, sweating, headache, and blurred vision.

Choice B reason: Assessing patient for tight clothing around the waist or a full bladder is the first priority action. These are common triggers of autonomic dysreflexia, which cause irritation or stimulation of the nerves below the level of injury. The nurse should remove any tight clothing, catheterize the patient if needed, or perform a bowel evacuation to relieve the pressure and prevent further complications.

Choice C reason: Reviewing the medication administration record for an antihypertensive order is a secondary action, after identifying and removing the trigger of autonomic dysreflexia. The nurse should administer the prescribed antihypertensive medication, such as nifedipine or nitroglycerin, to lower the blood pressure and prevent stroke, seizure, or cardiac arrest.

Choice D reason: Initiating oxygen via a nasal cannula and elevating patient's legs is not an appropriate action for a patient with autonomic dysreflexia. Oxygen therapy is not indicated for this condition, unless the patient has hypoxia or respiratory distress. Elevating the patient's legs can worsen the blood pressure by increasing the venous return and the cardiac output. The nurse should keep the patient in a sitting position to promote the blood flow to the lower extremities and reduce the blood pressure.

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Correct Answer is C

Explanation

Choice A reason: Diabetes mellitus Type 1 is a condition that affects the pancreas and the production of insulin, a hormone that regulates blood sugar levels. It does not directly cause anemia, but it can increase the risk of complications such as infections, ulcers, and nerve damage.

Choice B reason: Peripheral vascular disease is a condition that affects the blood vessels and the circulation of blood to the limbs. It does not directly cause anemia, but it can increase the risk of complications such as clots, wounds, and gangrene.

Choice C reason: Chronic kidney disease is a condition that affects the kidneys and their function of filtering waste and fluids from the blood. It can cause anemia by reducing the production of erythropoietin, a hormone that stimulates the bone marrow to make red blood cells.

Choice D reason: Hypertension is a condition that affects the blood pressure and the force of blood against the artery walls. It does not directly cause anemia, but it can increase the risk of complications such as stroke, heart attack, and kidney damage.

A. Apples and grapes. B. Popsicles, gelatin, or juice. C. Beans. D. Cheese.

Correct Answer is B

Explanation

Choice A (Apples and grapes): While fruits like apples and grapes are generally healthy options, they may not be the best choice for a client in sickle cell crisis. These fruits are high in fiber and may require a significant amount of chewing, which can be challenging for someone experiencing a sickle cell crisis.

Choice B (Popsicles, gelatin, or juice): This choice is the most suitable for a client in sickle cell crisis. During a crisis, it's important to stay hydrated, and these options provide hydration along with easily digestible carbohydrates, which can be beneficial for maintaining energy levels.

Choice C (Beans): While beans are a good source of protein and fiber, they may not be well tolerated during a sickle cell crisis due to their high fiber content.

Choice D (Cheese): Although cheese is a source of protein and calcium, it may not be the best option during a sickle cell crisis, as dairy products can be harder to digest and may not contribute to hydration.

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The nurse assesses a patient with a recent spinal cord injury at the level of thoracic 5 vertebrae. The patient's blood pressure is 184/95 mm Hg, has a flushed face and blurred vision. What priority action would the nurse complete first?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with anemia. Their medical history includes diabetes mellitus Type 1, hypertension, chronic kidney disease, and peripheral vascular disease. Which condition most likely contributes to their anemia?

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Correct Answer is B

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