When planning the care for a client who has a spinal cord injury, the nurse should give priority to which of these treatment measures first?
A)
monitoring the client's blood pressure
B)
listening for bowel sounds
C)
testing for motor strength
D)
palpating the client's bladder for fullness
A
Explanation:
A)
An exaggerated sympathetic response leads to autonomic dysreflexia, which can lead to a hypertensive crisis. A full bladder or distended bowel can trigger the response.
Analysis
Planning
Physiological Integrity: Reduction of Risk Potential
B)
An exaggerated sympathetic response leads to autonomic dysreflexia, which can lead to a hypertensive crisis. A full bladder or distended bowel can trigger the response.
Analysis
Planning
Physiological Integrity: Reduction of Risk Potential
C)
An exaggerated sympathetic response leads to autonomic dysreflexia, which can lead to a hypertensive crisis. A full bladder or distended bowel can trigger the response.
Analysis
Planning
Physiological Integrity: Reduction of Risk Potential
D)
An exaggerated sympathetic response leads to autonomic dysreflexia, which can lead to a hypertensive crisis. A full bladder or distended bowel can trigger the response.
Analysis
Planning
Physiological Integrity: Reduction of Risk Potential
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