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","E"]

Explanation

A) Pneumonia: Pneumonia is a direct cause of ARDS, as it involves direct inflammation and infection of the lung tissue, leading to impaired oxygen exchange and damage to the alveolar-capillary membrane. It results in fluid accumulation in the lungs, which is a key characteristic of ARDS.

B) Drowning: Drowning is another direct cause of ARDS. It involves the aspiration of water into the lungs, which directly damages lung tissue, causing pulmonary edema and impaired oxygenation.

C) Aspiration: Aspiration of food, liquid, or vomit into the lungs is also a direct cause of ARDS. The aspirated material can lead to chemical pneumonia, bacterial infection, and inflammation of the lungs, which in turn causes ARDS.

D) Sepsis: Sepsis is an indirect cause of ARDS. It can lead to widespread inflammation throughout the body, including the lungs, through the release of inflammatory mediators (cytokines, interleukins, etc.). These systemic inflammatory responses can increase capillary permeability in the lungs, causing fluid to leak into the alveoli, which leads to ARDS.

E) Blood Transfusion: Blood transfusion, particularly when associated with transfusion-related acute lung injury (TRALI), is an indirect cause of ARDS. TRALI is a serious complication that can result from receiving blood products, where the transfused blood causes an immune response leading to pulmonary damage. It indirectly triggers inflammation and fluid buildup in the lungs, contributing to ARDS.

A. there are no obvious symptoms or problems B. radiation therapy is ineffective because the ovaries are located so deep within the pelvis C. the causative cancer cell is resistant to chemotherapy or radiation D. ovarian cancer occurs primarily among women over age 70 that also have other complicating health problems

Correct Answer is ["A"]

Explanation

A) There are no obvious symptoms or problems: Ovarian cancer is often referred to as the "silent killer" because it tends to develop without noticeable symptoms in the early stages. When symptoms do appear, they are often vague and nonspecific, such as bloating, abdominal discomfort, or changes in bowel habits. By the time ovarian cancer is diagnosed, it is frequently at an advanced stage, making it more difficult to treat effectively. This lack of early, clear symptoms contributes significantly to the high death rate associated with the disease.

B) Radiation therapy is ineffective because the ovaries are located so deep within the pelvis: While ovarian cancer is located deep within the pelvis, radiation therapy can still be effective for certain types of tumors. However, the primary reason for high death rates is not the location of the ovaries, but the late-stage diagnosis and difficulty in detecting the cancer early.

C) The causative cancer cell is resistant to chemotherapy or radiation: While some ovarian cancer cells may exhibit resistance to treatment, this is not the main reason for the high mortality rate. The real issue is the lack of early detection, as ovarian cancer is often diagnosed when it has already spread beyond the ovaries. Early-stage ovarian cancer may be more responsive to treatment, but by the time symptoms are noticeable, the cancer is often advanced, which limits the effectiveness of chemotherapy and radiation.

D) Ovarian cancer occurs primarily among women over age 70 that also have other complicating health problems: Although the incidence of ovarian cancer increases with age, particularly after age 60, it is not the primary factor contributing to high death rates. Many women diagnosed with ovarian cancer are relatively healthy except for the cancer itself.

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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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Naxlex Comprehensive Predictor Exams

What does the nurse identify as INDIRECT cause of acute respiratory distress syndrome (ARDS) SELECT ALL THAT APPLY

Correct Answer is ["D","E"]

Explanation

In educating clients about ovarian cancer the nurse emphasizes death rates for ovarian cancer are high because:

Correct Answer is ["A"]

Explanation

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