The nurse assesses the patient with a spinal cord injury at the level C-7 and finds warm, flushed skin with profuse sweating above the level of injury, and pale, cold skin below the level of injury. The patient is bradycardic, but severely hypertensive. What are the priority nursing interventions?

Establish IV access apply 2L O2 via nasal cannula, and notify provider

Assess below injury for noxious stimuli anticipate order hypertensive medication

Administer acetaminophen and initiate intravenous (IV) fluids anticipate order for atropine

Lower the head of the bed and apply a cool compress to the forehead

Answer and Explanation

The Correct Answer is B

A) Establish IV access, apply 2L O2 via nasal cannula, and notify provider:
While establishing IV access and providing oxygen are important aspects of managing many emergencies, this patient's symptoms suggest the presence of autonomic dysreflexia rather than a primary respiratory or circulatory issue. In autonomic dysreflexia, the primary concern is to remove the noxious stimulus (such as a full bladder, bowel impaction, or tight clothing) that is causing the severe hypertension and bradycardia.

B) Assess below injury for noxious stimuli, anticipate order for hypertensive medication:
The patient’s symptoms are consistent with autonomic dysreflexia, a serious condition that occurs in individuals with a spinal cord injury at or above the T6 level. The body’s autonomic nervous system overreacts to noxious stimuli (such as a distended bladder, bowel impaction, or skin irritation) below the level of injury, leading to a severe hypertensive crisis, bradycardia, and sympathetic hyperactivity. The nurse should immediately assess for and relieve any noxious stimuli below the injury level (e.g., checking for a full bladder, constipation, or tight clothing) and anticipate an order for antihypertensive medications if the blood pressure remains elevated.

C) Administer acetaminophen and initiate intravenous (IV) fluids, anticipate order for atropine:
While pain and discomfort (which can exacerbate autonomic dysreflexia) may need to be managed, acetaminophen is not the priority in this case. The priority is addressing the underlying cause of autonomic dysreflexia, such as relieving noxious stimuli. Additionally, atropine is used for bradycardia, but in autonomic dysreflexia, the bradycardia is secondary to the hypertensive crisis and usually resolves once the noxious stimulus is removed.

D) Lower the head of the bed and apply a cool compress to the forehead:
Although lowering the head of the bed may help reduce intracranial pressure and applying a cool compress may provide comfort, these interventions do not address the underlying cause of the autonomic dysreflexia.

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Correct Answer is D

Explanation

A) Respiratory acidosis:
Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2) in the blood, leading to a decrease in pH. In the given blood gas values, the PaCO2 is 28 mmHg, which is lower than the normal range (35-45 mmHg), indicating that CO2 is being exhaled more than usual, not accumulating.

B) Metabolic acidosis:
Metabolic acidosis results from a decrease in bicarbonate (HCO3-) or an increase in acid in the body. However, in the provided values, the bicarbonate (HCO3-) is normal at 24 mEq/L, and the pH is elevated at 7.51, indicating alkalosis rather than acidosis

C) Metabolic alkalosis:
Metabolic alkalosis occurs when there is an increase in bicarbonate levels or excessive loss of acids, often associated with vomiting or diuretic use. However, in this case, the bicarbonate level (HCO3-) is normal, and the pH is more consistent with alkalosis due to respiratory factors, not metabolic causes.

D) Respiratory alkalosis:
Respiratory alkalosis occurs when there is excessive exhalation of CO2, leading to a rise in blood pH (alkalosis). The pH is 7.51, which is above the normal range (7.35-7.45), indicating alkalosis. Additionally, the PaCO2 is low at 28 mmHg, which suggests that the client is hyperventilating and exhaling too much CO2, confirming respiratory alkalosis as the correct interpretation.

A. Mask-like face and shuffling gait B. Lack of arm swing and bradykinesia C. Pill rolling of fingers and flat affect D. Difficulty swallowing and immobility

Correct Answer is D

Explanation

A) Mask-like face and shuffling gait:
While the mask-like face and shuffling gait are common clinical features of Parkinson's Disease (PD), they do not directly explain the fever or the patchy infiltrates seen on the chest x-ray. The mask-like face is due to reduced facial muscle activity and is associated with the motor symptoms of PD, while the shuffling gait results from bradykinesia (slowness of movement).

B) Lack of arm swing and bradykinesia:
Lack of arm swing and bradykinesia are motor symptoms of PD that are indicative of decreased movement and muscle rigidity. While they impact a patient’s mobility and dexterity, they are not directly associated with lung infiltrates or fever.

C) Pill rolling of fingers and flat affect:
Pill rolling (a characteristic tremor where patients move their fingers as if rolling a pill) and flat affect (a reduced emotional expression) are hallmark features of Parkinson's Disease, but again, they do not explain the fever or lung infiltrates.

D) Difficulty swallowing and immobility:
Difficulty swallowing (dysphagia) is a common and serious symptom in patients with Parkinson's Disease. Due to the loss of control over the muscles involved in swallowing, patients with PD are at high risk for aspiration (food, liquids, or saliva entering the lungs), which can lead to aspiration pneumonia. This condition often presents with fever, chest infiltrates, and respiratory distress, which directly correlates with the patient's fever and lung infiltrates seen on the chest x-ray.

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The nurse assesses the patient with a spinal cord injury at the level C-7 and finds warm, flushed skin with profuse sweating above the level of injury, and pale, cold skin below the level of injury. The patient is bradycardic, but severely hypertensive. What are the priority nursing interventions?

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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