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 A

Explanation

Choice A reason: Eyes are deviated to the right is an assessment finding that indicates increased intracranial pressure and possible herniation of the brain. It is a sign of cranial nerve III palsy, which affects the movement of the eye and the size of the pupil. It is a medical emergency that requires immediate intervention.

Choice B reason: Amnesia to the cause of the trauma is an assessment finding that indicates memory loss and possible concussion. It is a sign of damage to the temporal lobe, which is involved in memory formation and retrieval. It is not a medical emergency, but it requires further evaluation and monitoring.

Choice C reason: Complaint of mild headache is an assessment finding that indicates pain and discomfort. It is a common symptom of traumatic brain injury, but it is not specific or severe. It can be managed with analgesics and rest.

Choice D reason: Pupils constrict from 5 mm to 2 mm with direct light stimulus is an assessment finding that indicates normal pupillary response. It is a sign of intact cranial nerve II and III function, which control the vision and the pupil size. It is not a cause for concern or notification.

A. macrocytic, normochromic B. microcytic, hypochromic C. normocytic, normochromic D. microcytic, normochromic

Correct Answer is A

Explanation

Choice A reason: This is correct. Folic acid deficiency causes macrocytic, normochromic anemia, which means that the red blood cells are larger than normal, but have normal color and hemoglobin content. Folic acid is a vitamin that is needed for the synthesis of DNA and the maturation of red blood cells.

Choice B reason: This is incorrect. Microcytic, hypochromic anemia means that the red blood cells are smaller than normal and have less color and hemoglobin content. This type of anemia is caused by iron deficiency, not folic acid deficiency.

Choice C reason: This is incorrect. Normocytic, normochromic anemia means that the red blood cells are normal in size, color, and hemoglobin content, but there are fewer of them. This type of anemia is caused by blood loss, hemolysis, or bone marrow failure, not folic acid deficiency.

Choice D reason: This is incorrect. Microcytic, normochromic anemia means that the red blood cells are smaller than normal, but have normal color and hemoglobin content. This type of anemia is rare and is caused by disorders of red blood cell production, such as thalassemia or sideroblastic anemia, not folic acid deficiency.

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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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