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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Risk for Falls is the priority nursing diagnosis for a patient with Parkinson disease, as the disease affects the patient's balance, coordination, and posture. The patient may have difficulty walking, turning, and standing, which increases the risk of falling and injuring themselves. The nurse should implement interventions to prevent falls, such as providing assistive devices, removing environmental hazards, and educating the patient and family about fall prevention.
Choice B reason: Ineffective Self-Care Ability related to cognitive deficit is a possible nursing diagnosis for a patient with Parkinson disease, as the disease may impair the patient's memory, judgment, and problem-solving skills. The patient may have difficulty performing activities of daily living, such as bathing, dressing, and grooming. The nurse should assess the patient's self-care abilities, provide assistance as needed, and encourage the patient to maintain their independence and dignity.
Choice C reason: Risk for Impaired Skin Integrity related to uncontrolled hand tremors is another possible nursing diagnosis for a patient with Parkinson disease, as the disease causes involuntary movements of the hands, arms, and legs. The patient may scratch, rub, or injure their skin due to the tremors. The nurse should monitor the patient's skin condition, provide skin care, and protect the patient from skin breakdown.
Choice D reason: Nutrition: Less Than Body Requirements related to frequent nausea during meals is a potential nursing diagnosis for a patient with Parkinson disease, as the disease may affect the patient's appetite, digestion, and swallowing. The patient may experience nausea, vomiting, constipation, or dysphagia, which can lead to malnutrition and dehydration. The nurse should assess the patient's nutritional status, provide dietary modifications, and ensure adequate fluid intake.
Correct Answer is D
Explanation
Choice A reason: This is incorrect. Arm and leg weakness, paresthesia, blurred vision, and facial frown are not specific to Parkinson disease, but may be seen in other neurological disorders, such as multiple sclerosis or stroke.
Choice B reason: This is incorrect. Uncontrollable rapid jerky movements in arms, trunk and facial muscles are characteristic of Huntington disease, not Parkinson disease. Huntington disease is a genetic disorder that causes progressive degeneration of the nerve cells in the brain.
Choice C reason: This is incorrect. Stumbling, backward tilt of the head, quick fluttering hand movements, and quick uncontrolled gait are signs of cerebellar ataxia, not Parkinson disease. Cerebellar ataxia is a disorder that affects the coordination and balance of the movements, caused by damage to the cerebellum.
Choice D reason: This is correct. Hand tremors, bradykinesia, skeletal muscle rigidity, and postural instability are the cardinal signs and symptoms of Parkinson disease. Parkinson disease is a chronic and progressive disorder that affects the dopamine-producing neurons in the brain, resulting in movement problems.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today