The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

Elevate the head of the bed, loosen clothing, and check the urinary catheter for obstruction

Elevate the head of the bed and apply a cool compress to the forehead

Place in Semi-Fowler's position and establish IV access

Establish IV access, apply 2 liters of nasal oxygen, and contact the health care provider

Answer and Explanation

The Correct Answer is A

A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.

B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.

C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.

D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.

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Correct Answer is D

Explanation

A. EEG is a monitoring tool for brain activity, but it is not a prerequisite for ventriculostomy placement.

B. While the procedure is carefully managed to reduce infection risk, ventriculostomy does have an infection risk due to its invasive nature.

C. Ventriculostomy is not inserted via the femoral artery; it is placed directly in the brain’s ventricles.

D. A ventriculostomy is used to monitor ICP and allows for the drainage of cerebrospinal fluid, which helps in managing elevated ICP in patients with brain injuries.

A. Remove all foreign objects B. Stabilize object and lightly protect with covering C. Provide a light meal with clear liquids D. Instruct the patient vigorously blow their nose if necessary

Correct Answer is B

Explanation

A. Removing objects is contraindicated, as it can worsen the injury.

B. Stabilizing the object and covering it prevents further injury until medical evaluation, which is critical in cases of eye trauma. Moving or removing a foreign body could lead to additional damage.

C. Providing a light meal is not directly related to managing eye trauma and does not address the immediate concern.

D. Blowing the nose could increase intraocular pressure, potentially worsening the injury.

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ABG Value	Normal Range
pH	7.35- 7.45
PaCO2	35-45 mm Hg
HCO3	22-25 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating on the placement of a ventriculostomy (intraventricular catheter) to the patient diagnosed with a brain injury and their family. The nurse states, "The ventriculostomy is placed:

Correct Answer is D

Explanation

The nurse is caring for a patient who has sustained eye trauma as a result of a motor vehicle crash (MVC). Which intervention should the nurse provide regarding a foreign body?

Correct Answer is B

Explanation

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