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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

Asking the patient why they are behaving inappropriately does not address or stop the behavior. This approach may escalate the situation, leading to further discomfort for others.

Choice B rationale

Recommending 1: observation without addressing the behavior does not teach social boundaries. It is a passive solution that misses the opportunity for behavior correction.

Choice C rationale

Pointing out the behavior as unacceptable sets clear boundaries and educates the patient on appropriate social conduct. It creates an opportunity for the patient to reflect and adjust their behavior.

Choice D rationale

Having the patient return to their room may temporarily stop the behavior but does not educate the patient or reinforce appropriate boundaries for public settings.

A. The patient will recall events from childhood. B. The patient will return to work as a corporate attorney. C. The patient will actively participate in the rehabilitation process as appropriate. D. The patient will demonstrate improved motor coordination within two weeks.

Correct Answer is C

Explanation

Choice A rationale

Childhood memory recall reflects cognitive functioning but is unrelated to the patient's rehabilitation involvement, which focuses on regaining lost functional capacities following injury. Such a goal lacks immediate functional relevance.

Choice B rationale

Returning to work as a corporate attorney may be an eventual aim but depends on higher cognitive recovery levels and is too specific. Early rehabilitation outcomes focus on participation in the recovery process.

Choice C rationale

Active participation indicates readiness and willingness to engage in therapies essential for regaining lost functions. It aligns with goals for a transition from acute care to rehabilitation emphasizing functional improvement.

Choice D rationale

Motor coordination improvements require therapy timelines extending beyond two weeks. Such a rigid short-term goal undermines individualized rehabilitation focusing on measurable progress over more realistic durations.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse on the brain injury unit observes a patient who displays inappropriate sexual behavior.What would be the best response by the nurse?

Correct Answer is C

Explanation

The nurse is caring for a patient who had a serious head injury.The patient has recovered enough to be transferred to a rehabilitation facility.Which of the following rehabilitation goals would be most appropriate for the patient?

Correct Answer is C

Explanation

The nurse knows that a common presentation that happens early in HIV infections is:

A client with an intracranial aneurysm that resulted in a cerebral bleed is to be discharged to a rehabilitation facility.Which of the following rehabilitation outcomes would be appropriate for this client?

A 78-year-old client is admitted to the Emergency Department with numbness and weakness of the right arm and slurred speech.Which nursing intervention is a priority?

The nurse is reviewing discharge instructions for a patient with a spinal cord injury to T-10 going home with an indwelling urinary catheter.What would the nurse emphasize about catheter care? (Select All that Apply.)

To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid:

The nurse is performing an admission assessment on a client with a diagnosis of detached retina.Which of the following is associated with this eye disorder?

A client's daughter asks the nurse for assistance in communicating with her mother who has sensorineural hearing loss.Which point is appropriate for the nurse to teach?

Which behaviors by the patient diagnosed with a chronic head injury would the nurse expect to find?

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?