The nurse is caring for a patient with a spinal cord injury (SCI) who is about to be transferred to a wheelchair for Physical Therapy. The patient complains of feeling dizzy and is diaphoretic. What would be the priority nursing action?
Establish IV access and bolus 250 mL normal saline
Assess for bladder distension and perform digital disimpaction
Reschedule the therapy session for later in the day
Lower the head of the bed and obtain vital signs
The Correct Answer is D
A. Establishing IV access may be necessary if hypotension persists but is not the initial priority.
B. Bladder distension assessment is essential for managing autonomic dysreflexia in SCI patients; however, symptoms here suggest orthostatic hypotension rather than autonomic dysreflexia.
C. Rescheduling therapy may be considered if dizziness persists, but it does not address the immediate concern.
D. Lowering the head of the bed and obtaining vital signs can help stabilize blood pressure and monitor for orthostatic hypotension, which is common in patients with SCI due to autonomic dysfunction. This intervention helps to prevent syncope.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The head tilt chin lift method should be avoided due to the risk of aggravating a spinal injury; the jaw-thrust maneuver is safer if airway management is necessary.
B. While controlling bleeding is important, cervical spine stabilization takes priority in trauma with suspected spinal injury.
C. Not moving the victim is appropriate, but stabilizing the cervical spine provides active support to avoid further injury.
D. Stabilizing the cervical spine is crucial to prevent potential spinal cord damage in an unconscious trauma victim, particularly in a motor vehicle accident. This action helps prevent exacerbation of any spinal injury.
Correct Answer is A
Explanation
A. A patient found facedown in water is at high risk of anoxic brain injury due to potential prolonged oxygen deprivation, which is directly associated with lack of oxygen to the brain.
B. Multiple concussions can lead to other types of brain injury but are less associated with anoxic injury than prolonged oxygen deprivation.
C. A basilar skull fracture can cause complications such as CSF leaks but does not directly cause an anoxic brain injury.
D. An epidural hematoma may increase ICP, but with timely intervention, anoxic injury may be avoided; anoxic brain injury is more directly related to oxygen deprivation.
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