Author Question: A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is ... (Read 127 times)

Collmarie · **on:** Jun 25, 2018

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first?

a. Initiate oxygen via a nasal cannula.
b. Place the client in a supine position.
c. Palpate the bladder for distention.
d. Administer a prescribed beta blocker.

Question 2

A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should alert the nurse to urgently communicate with the health care provider?

a. Auscultated stridor
b. Weak pedal pulses
c. Difficulty swallowing
d. Inability to shrug shoulders

anoriega3 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
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.

Answer to Question 2

ANS: A
Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery.