A 39-year-old patient is being evaluated for a possible spinal ...

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A 39-year-old patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action?
 
  a. The patient has new onset weakness of both legs.
  b. The patient complains of chronic severe back pain.
  c. The patient starts to cry and says, I feel hopeless.
  d. The patient expresses anxiety about having surgery.

Question 2

A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, I have a pounding headache and I feel sick to my stomach. Which action should the nurse take first?
 
  a. Check for a fecal impaction.
  b. Give the prescribed analgesic.
  c. Assess the blood pressure (BP).
  d. Notify the health care provider.

[k2629]

Answer to Question 1

ANS: A
The new onset of symptoms indicates cord compression, which is an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness.

Answer to Question 2

ANS: C
The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. After checking the BP, the nurse may assess for a fecal impaction using lidocaine jelly to prevent further increased BP.