Your spinal cord injury (SCI) patient complains of a throbbing headache and nausea. You observe the patient has marked diaphoresis, and you think the patient may have autonomic dysreflexia. Place the following interventions in the order you would complete them.

Check the blood pressure

Obtain a bladder scan

Notify the doctor

Elevate the head of the bed to 45 degrees

Answer and Explanation

The Correct Answer is D,A,B,C

Choice D reason: Elevating the head of the bed to 45 degrees is the first intervention the nurse should perform. This position helps lower the patient's blood pressure by promoting venous pooling in the lower extremities and reducing the return of blood to the heart. It also aids in better breathing and overall comfort.

Choice A reason: Checking the blood pressure is crucial in this situation to confirm if the patient is experiencing autonomic dysreflexia, which is characterized by a sudden and severe increase in blood pressure. This step helps in assessing the severity of the condition and guiding subsequent interventions.

Choice B reason: Obtaining a bladder scan is important because a full bladder is a common trigger of autonomic dysreflexia. By identifying and addressing the cause of the distension, the nurse can help alleviate the symptoms and prevent further complications.

Choice C reason: Notifying the doctor is a critical step, as autonomic dysreflexia is a medical emergency that requires prompt medical intervention. The healthcare provider can give additional orders and may administer medication to control the patient's blood pressure and relieve symptoms.

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Correct Answer is B

Explanation

Choice A reason: Nursing supervisors generally oversee nursing staff and ensure that patient care standards are being met, but they are not primarily responsible for developing individualized plans of care.

Choice B reason: Registered nurses (RNs) are trained and licensed to develop individualized plans of care that include nursing diagnoses, interventions, and outcomes. They work closely with patients to understand their needs and create a plan that supports their health goals, including self-management care.

Choice C reason: Health care providers, such as medical doctors (MDs) or nurse practitioners (NPs), are responsible for diagnosing and treating medical conditions, but the development of detailed nursing care plans is typically outside their primary scope of practice.

Choice D reason: Licensed practical/vocational nurses (LPN/VN) provide basic nursing care and assist with patient care activities, but they do not generally develop comprehensive nursing care plans, which require the higher level of training and education that RNs receive.

A. Increased blood pressure B. Increased respiratory rate C. Increased heart rate

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

Explanation

Choice A reason: Increased blood pressure is a common physiological response to pain. When a person experiences pain, the body's sympathetic nervous system is activated, causing an increase in heart rate and blood pressure. This response is part of the body's fight-or-flight mechanism, intended to help cope with the stressful situation.

Choice B reason: Increased respiratory rate is another sign of unrelieved pain. Pain can lead to rapid, shallow breathing as the body reacts to the discomfort. This response can help deliver more oxygen to tissues during times of stress but can also contribute to feelings of anxiety and fatigue if it continues over a prolonged period.

Choice C reason: Increased heart rate is a typical response to pain. Just like increased blood pressure, the heart rate rises as part of the body's sympathetic response to pain, which prepares the body to either confront or escape the source of pain. Monitoring heart rate can therefore provide critical information about the patient's pain levels and overall physiological state.

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Your spinal cord injury (SCI) patient complains of a throbbing headache and nausea. You observe the patient has marked diaphoresis, and you think the patient may have autonomic dysreflexia. Place the following interventions in the order you would complete them.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In any clinical setting, which health care team member is responsible for developing an individualized plan of care that includes nursing diagnoses, interventions, and outcomes, including the patient's self-management care plan?

Correct Answer is B

Explanation

Physical signs of unrelieved pain include which of the following? Select all that apply.

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

Explanation

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