A patient who has suffered a spinal cord injury at C4 is experiencing a sudden change in condition. His BP is 186/101; heart rate is 45; and he is profusely sweating and complaining of "not feeling right." The nurse should
A)
call a "Code Blue."
B)
page physician stat. and ask for an antihypertensive medication.
C)
palpate his bladder for overdistention.
D)
place his bed flat and elevate the foot of the bed.
Ans:
C
Feedback:
The most common causes of spastic bladder dysfunction are spinal cord lesions such as spinal cord injury, herniated intervertebral disk, vascular lesions, tumors, and myelitis. Because the injury interrupts CNS control of sympathetic reflexes in the spinal cord, severe hypertension, bradycardia, and sweating can be triggered by insertion of a catheter or mild overdistention of the bladder. The patient does not qualify for a Code Blue since he still has a pulse and is breathing. Antihypertensive medication is not necessary if the bladder is emptied. Placing him flat with the foot of the bed elevated will not help this situation.
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