A nurse is caring for a client who has quadriplegia due to a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. What should the nurse prioritize as the initial action?
Lower the client's legs.
Check for a full bladder.
Administer a nitrate antihypertensive.
Administer pain medication.
The Correct Answer is B
A. Lowering the client's legs is not effective in managing autonomic dysreflexia and may not alleviate the cause of the high blood pressure.
B. Checking for a full bladder is the priority because bladder distension is a common trigger for autonomic dysreflexia in clients with spinal cord injuries, and relieving it can reduce the severe hypertensive response.
C. Antihypertensives may be used if non-pharmacological measures fail, but addressing the cause is the first action.
D. Pain medication is not indicated as the immediate intervention for autonomic dysreflexia, as the priority is identifying and removing the trigger.
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Correct Answer is C
Explanation
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D. Loosening the halo device could compromise the stabilization it provides and may not effectively address skin integrity issues.
Correct Answer is C
Explanation
A. Diplopia is a concerning symptom but does not indicate immediate deterioration in neurological status like a change in GCS does.
B. Ataxia is also significant but is less acute than a drop in GCS score.
C. A change in the Glasgow Coma Scale score from 13 to 11 indicates a worsening level of consciousness and necessitates immediate reporting, as it may suggest increased intracranial pressure or other complications.
D. A decrease in heart rate from 76 to 69 bpm is not significant enough in the context of TBI to warrant immediate reporting, as it remains within a normal range.