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. .

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Correct Answer is D

Explanation

Choice A rationale

Clopidogrel is an antiplatelet agent that prevents platelet aggregation but does not affect arrhythmias. It reduces clot formation risk, which is critical for patients with a history of TIA or stroke.

Choice B rationale

Clopidogrel does not lower blood pressure. It works by inhibiting platelet aggregation to prevent thrombus formation, not addressing the mechanisms of hypertension or blood pressure control.

Choice C rationale

Clopidogrel does not directly affect peripheral artery disease symptoms, such as leg pain. It is used to reduce the risk of thrombotic events like strokes and heart attacks by preventing platelet aggregation.

Choice D rationale

Clopidogrel inhibits platelet aggregation by blocking the ADP receptor on platelets, reducing the risk of clot formation. This is crucial for preventing ischemic events in patients with a history of TIA.

A. Decreased level of consciousness. B. Elevated blood pressure and patient reports headache. C. Patient has vomited once and reports persistent nausea. D. Positive Babinski's sign. E. Fever and cardiac dysrhythmias.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

A decreased level of consciousness indicates possible intracranial hemorrhage, a complication of thrombolytic therapy. Altered mental status may result from brain bleeding disrupting normal neural function.

Choice B rationale

Elevated blood pressure and headache suggest intracranial hemorrhage, as the rise in intracranial pressure often accompanies vascular disruption and neurogenic pain.

Choice C rationale

Vomiting and persistent nausea can signal intracranial hemorrhage, as blood irritating brain tissue and increasing pressure stimulates the emetic center in the medulla.

Choice D rationale

Positive Babinski's sign is associated with upper motor neuron lesions but is not a direct indicator of thrombolytic therapy complications such as intracranial bleeding.

Choice E rationale

Fever and cardiac dysrhythmias do not directly indicate thrombolytic therapy complications. Dysrhythmias may stem from electrolyte disturbances or infections unrelated to hemorrhage.

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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?

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Correct Answer is D

Explanation

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Correct Answer is ["A","B","C"]

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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?