A patient with quadriplegia from a C5 injury is wearing a Halo vest and begins to experience a throbbing headache and nausea. What should the nurse do first?
a. Check the patient's blood pressure.
b. Do a digital rectal examination for the presence of an impaction.
c. Notify the charge nurse or physician immediately of the patient's headache.
d. Advise the patient that sitting in the wheelchair will help relieve the headache.
ANS: A
The patient has symptoms of autonomic dysreflexia, which can occur in patients with injuries above the T6 level. B. Once blood pressure is checked and under control, then further assessment can be done to find the source of the problem. D. Sitting will not fix the problem. C. The physician or charge nurse can be notified as needed once further assessment and intervention are completed.
You might also like to view...
A 35-year-old client with a long history of schizophrenia who often forgets to take his medication is admitted to an inpatient unit after police found him threatening passengers on a bus. This is his fourth admission in 3 months
This frequent re-hospitalization is an example of: a. Recidivism b. Symptom exacerbation c. Noncompliance d. Rejection
Unlicensed personnel are not licensed by the state in their own right. Why is it that these persons can perform delegated tasks?
1. They practice on the license of the professionals delegating the tasks. 2. They are sanctioned by the American Hospital Association as an exception to the requirement for a license. 3. They work under the auspices and licensure of the institution, not the professional nurse. 4. They are sanctioned by the state nurse practice act as an exception to the requirement for licensure.
The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate?
a. "Do you have a history of a heart attack?" b. "Is there a family history of endocarditis?" c. "Have you had any recent immunizations?" d. "Have you had dental work done recently?"
A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks?
1. Revise nursing diagnosis. 2. Reassess blood pressure reading. 3. Retake blood pressure after medication. 4. Administer new blood pressure medication. 5. Change goal to blood pressure less than 140/90. a. 1, 5, 2, 4, 3 b. 2, 1, 5, 4, 3 c. 4, 3, 1, 5, 2 d. 5, 4, 5, 1, 2