A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling.". Which is the most appropriate initial reaction by the nurse?
1. Try to calm the patient and make the environment soothing.
2. Assess for a full bladder.
3. Notify the health care provider.
4. Prepare the patient for diagnostic radiography.
2
Rationale 1: A calm, soothing environment is fine, but not what the patient needs in this case.
Rationale 2: Autonomic dysreflexia occurs in patients with injury at level T6 or higher. It is a life-threatening condition that requires immediate intervention. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea.
Rationale 3: The nurse must perform an assessment first, then communicate the findings to the health care provider.
Rationale 4: This would not be an initial response for this patient.
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When a nurse asks a client to place the right arm behind the head, the nurse is testing for which range of motion?
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