A patient with a cervical spinal cord injury suddenly develops severe headache, sweating above the injury, nasal congestion and a blood pressure of 190/100 mmHg. What is the priority nursing action?
Correct answer: B. Sit the patient upright and assess for bladder distension
- A. Place the patient flat and offer oral fluids
- B. Sit the patient upright and assess for bladder distension
- C. Apply a warm blanket and reduce room lighting
- D. Encourage the patient to walk to improve circulation
Explanation
These findings suggest autonomic dysreflexia, a medical emergency in patients with injuries at or above T6. Sitting the patient upright helps lower blood pressure while the nurse urgently looks for triggers such as a blocked or distended bladder.
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About Neurological Nursing
Covers nursing assessment and management of stroke, epilepsy, meningitis, raised intracranial pressure, head injury, spinal cord disorders, Parkinson disease and multiple sclerosis. Key areas include level of consciousness, pupil responses, motor and sensory findings, seizure precautions and distinguishing upper motor neuron from lower motor neuron signs.
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