The nurse is caring for a patient with a spinal cord injury at the level of C-7. The patient is having a severe headache, hypertension, bradycardia, diaphoresis, and flushing of the face with pale, cold skin below the level of the injury.
What are the priority nursing interventions?
Elevate the head of the bed, loosen clothing, check the urinary catheter for obstruction.
Elevate the head of the bed and apply a cool compress to the forehead.
Establish IV access, apply 2L of oxygen via nasal cannula, notify provider.
Place in supine position and establish IV access for medication administration.
The Correct Answer is A
Choice A rationale
Elevating the head of the bed reduces blood pressure and intracranial pressure. Loosening restrictive clothing addresses triggers of autonomic dysreflexia, while checking the catheter resolves bladder-related stimulus for this medical emergency.
Choice B rationale
Although elevating the head of the bed is correct, applying a cool compress doesn't address the root cause of autonomic dysreflexia. The compress offers temporary relief without resolving the underlying triggers.
Choice C rationale
IV access and oxygen application are secondary interventions. The priority is resolving triggers like bladder distension or tight clothing to prevent further autonomic dysreflexia complications.
Choice D rationale
Placing the patient in a supine position can exacerbate hypertension and intracranial pressure. This positioning fails to address triggers of autonomic dysreflexia and is contraindicated in this condition. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Elevating the head of the bed reduces blood pressure and intracranial pressure. Loosening restrictive clothing addresses triggers of autonomic dysreflexia, while checking the catheter resolves bladder-related stimulus for this medical emergency.
Choice B rationale
Although elevating the head of the bed is correct, applying a cool compress doesn't address the root cause of autonomic dysreflexia. The compress offers temporary relief without resolving the underlying triggers.
Choice C rationale
IV access and oxygen application are secondary interventions. The priority is resolving triggers like bladder distension or tight clothing to prevent further autonomic dysreflexia complications.
Choice D rationale
Placing the patient in a supine position can exacerbate hypertension and intracranial pressure. This positioning fails to address triggers of autonomic dysreflexia and is contraindicated in this condition. .
Correct Answer is D
Explanation
Choice A rationale
Absence of short-term memory loss may be desirable but depends on the injury's severity and therapy progression. Memory recovery is inconsistent and often impractical as a definitive short-term outcome goal.
Choice B rationale
Resuming construction work is unrealistic within three weeks considering potential cognitive and physical impairments. This task exceeds achievable rehabilitation milestones, emphasizing safety over rapid return to demanding roles.
Choice C rationale
Pre-injury personality traits may not fully return, as emotional and personality changes often result from cerebral insults. Emotional stability is feasible but pre-injury personality restoration is speculative.
Choice D rationale
Medication adherence reflects successful cognitive rehabilitation, supporting long-term health stability by preventing further complications. This outcome is realistic and appropriate for patients recovering from intracranial injuries. .
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