Author Question: A patient with a spinal cord injury at the T1 level complains of a severe headache and an anxious ... (Read 43 times)

Cooldude101 · **on:** Jun 25, 2018

A patient with a spinal cord injury at the T1 level complains of a severe headache and an anxious feeling. Which is the most appropriate initial reaction by the nurse?

1. to try to calm the patient and make the environment soothing
2. to assess for a full bladder
3. to notify the healthcare provider
4. to prepare the patient for diagnostic radiography

Question 2

A school nurse is called after a student falls down a flight of stairs. The student is breathing but unconscious. After calling the ambulance, what should the nurse do?

1. assess the neck for movement
2. place the patient on the side to prevent aspiration
3. immobilize the neck, securing the head
4. try to rouse the patient by gently shaking the shoulders

Tonny · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 2
Autonomic dysreflexia occurs in patients with injury at level T6 or higher and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing environment is fine, but not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.

Answer to Question 2

Correct Answer: 3
Guidelines for emergency care include avoiding flexing, extending, or rotating the neck; immobilizing the neck; and securing the head. Assessing the neck for movement could cause or exacerbate a cervical injury. The side-lying position should be used if the patient vomits; however, this position should not be used in the immediate care of this patient. This patient is unconscious, and the nurse must protect the neck from any (or any further) damage. Rousing the patient by shaking could cause damage to the spinal cord.