A patient with a spinal cord injury at T3–T4 experiences a sudden increase in blood pressure (BP) and has cool, pale, gooseflesh skin on the lower extremities. What should the nurse do while awaiting physician orders? (Select all that apply.)
a. Monitor BP every 5 minutes.
b. Place the patient in supine position.
c. Check to see if the indwelling catheter is patent.
d. Perform a rectal examination to determine if impaction is present.
e. Place elastic stockings on the patient's legs.
ANS: A, C, D
The patient is experiencing autonomic dysreflexia, which can cause hypertension and bradycardia. The nurse should monitor BP and then check for catheter patency and impaction, both of which can cause dysreflexia. The patient should be placed in high Fowler's position, and elastic stockings should be removed to allow blood to pool and reduce BP.
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The nurse is caring for a 33-year-old woman who is experiencing pregnancy-induced hypertension (PIH). On the first visit, the nurse focuses on assessing
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Nurses involved in research assume different roles, based on their level of education. Which best describes the role of the BSN-prepared nurse in research?
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