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 ["A","B","C"]

Explanation

Choice A rationale

Proper nutrition, exercise, and stress reduction enhance psychological well-being, stimulating endorphin release, which improves mood and resilience, essential for managing chronic conditions like HIV.

Choice B rationale

These factors bolster immune function by reducing cortisol levels that impair immunity, supporting T-cell activity and promoting resistance against opportunistic infections common in HIV patients.

Choice C rationale

Maintaining strength and independence aids patients in daily functioning, reducing dependency and enhancing self-efficacy, which is critical for long-term adherence to therapeutic regimens in HIV.

Choice D rationale

Preventing virus transmission requires safe practices, not lifestyle changes alone. Nutrition and exercise cannot alter transmission mechanisms like exposure to body fluids.

Choice E rationale

Eliminating HIV completely necessitates antiretroviral therapy and advancements in medical science; lifestyle modifications alone are insufficient against viral integration within host DNA.

A. Prepare to administer recombinant tissue plasminogen activator (t-PA). B. Assist with transport to a STAT non-contrast computed tomography scan of the head. C. Perform a STAT EKG and assist with a STAT chest X-ray. D. Notify the speech and language pathologist for a STAT dysphagia evaluation.

Correct Answer is B

Explanation

Choice A rationale

Administering recombinant tissue plasminogen activator (t-PA) may be necessary, but confirming ischemic stroke via CT scan precedes treatment to rule out hemorrhagic stroke, which contraindicates t-PA.

Choice B rationale

Performing a STAT non-contrast CT scan of the head is the priority to differentiate between ischemic and hemorrhagic stroke, enabling appropriate and timely intervention.

Choice C rationale

A STAT EKG and chest X-ray, though helpful in identifying concurrent cardiac or pulmonary issues, are not immediate priorities in acute stroke evaluation.

Choice D rationale

While assessing dysphagia is critical post-stroke, it is not a priority during initial stroke evaluation, which focuses on rapid imaging and differentiation of stroke type. .

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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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Naxlex Comprehensive Predictor Exams

The nurse should educate clients who are HIV+ on proper nutrition, exercise, and stress reduction because these factors will: (Select All that Apply.)

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

Explanation

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Correct Answer is B

Explanation

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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?