A quadriplegic patient with a C5 injury has return of function of the lower motor neurons and is beginning rehabilitation. The patient is in a halo vest
As the nurse prepares to transfer the patient to a wheelchair, the patient complains of a throbbing headache and nausea, and the nurse notes that the patient's face looks flushed. 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. Advise the patient that sitting in the wheelchair will help relieve the headache.
d. Notify the RN or physician immediately of the patient's headache.
ANS: A
The patient has symptoms of autonomic dysreflexia, which can occur in patients with injuries above the T6 level. Once blood pressure is checked and under control, then further assessment can be done to find the source of the problem. Sitting will not fix the problem. The physician can be notified as needed once further assessment and intervention are completed.
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