A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse's first action?
a. Palpate the area over the bladder for dis-tention.
b. Place the client in the Trendelenburg posi-tion.
c. Administer oxygen via a nasal cannula.
d. Perform bilateral carotid massage.
A
The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.
You might also like to view...
The nurse is demonstrating to a patient the proper steps for breastfeeding a newborn. Put these steps in the logical order that would assist the patient in placing the newborn to her breast
Click and drag the options below to move them up or down. 1. Tickle the newborn's lips with the nipple. 2. Allow the newborn to latch on to the nipple. 3. The newborn opens her mouth wide. 4. Have the newborn face the mother tummy to tummy. 5. Position the newborn so the nose is at the level of the nipple.
The hospice nurse is educating a client's family on the physical signs of approaching death. The nurse knows that the education has been effective when the family says they will know that death is imminent when they see which of the following? Select all that apply.
a. Cyanosis of dependent areas b. Irregular respiratory rate c. Bowel incontinence d. Restlessness e. Increased body temperature
When evaluating the correlational relationship between exercise and resting blood pressure, which of the following describes the most significant correlation?
a. -.9 b. .8 c. .1 d. -.2
The patient comes to the emergency department with a blood pressure of 200/120 mmHg. The physician orders hydralazine (Apresoline) IV. What will the nurse's priority assessment include?
1. Hypotension and bradycardia 2. Hypotension and hyperthermia 3. Hypotension and tachycardia 4. Hypotension and tachypnea