An adolescent recovering from a spinal cord injury calls out for help. The patient's face is bright red, and the patient is experiencing a severe headache. What is the first thing that the nurse should do for this patient?
A) Administer mouth-to-mouth resuscitation.
B) Assess if the urinary retention catheter is blocked.
C) Massage the lower extremities to cause vasodilation.
D) Lower the head of the bed to increase cerebral circulation.
B
Feedback:
The patient is demonstrating signs of autonomic dysreflexia, which include extreme hypertension, tachycardia, flushed face, and severe occipital headache. This can occur if the patient's bladder is allowed to fill. The resultant sensory stimulation relayed to the damaged cord can initiate a powerful sympathetic reflex reaction. The nurse should assess that the patient's urinary catheter is not obstructed, so urine can flow freely and reduce the sensory stimulation. The patient is talking, so mouth-to-mouth resuscitation is not necessary. Massaging the lower extremities and lowering the head of the bed will not relieve the sensory stimulation caused by the blocked urinary catheter.
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