Practice Question
A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The blood pressure is significantly elevated to 190/100. The first action by the nurse is to:
Answer Choices:
Correct Answer:
Elevate the head of the bed immediately and notify the provider.
Rationale:
🟡 The client’s symptoms (severe headache, flushing, and hypertension) indicate autonomic dysreflexia, a life-threatening complication of spinal cord lesions above T6.
🟡 The first priority is to reduce blood pressure by sitting the client upright, which helps pool blood in the lower extremities.
🟡 After positioning, the cause (bladder or bowel distension, tight clothing) should be identified and corrected.
🟡 Immediate provider notification is crucial if symptoms persist, as stroke risk is high.
🟡 Tylenol is not appropriate because the headache is secondary to hypertensive crisis, not pain alone.
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This question is from Adult Health Med surg-viterbo University which contains 79 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Adult Health
- Answer Choices: 4