A patient with a thoracic spinal cord injury has a sudden severe headache, flushed skin above the injury and a blood pressure of 190/110 mmHg. Which action should the nurse take first?
Correct answer: B. Sit the patient upright and assess for a trigger
- A. Place the patient flat and give a sedative
- B. Sit the patient upright and assess for a trigger
- C. Encourage the patient to walk in the corridor
- D. Apply a warm blanket to the lower limbs
Explanation
These findings suggest autonomic dysreflexia, a medical emergency caused by an irritating stimulus below the spinal injury, commonly bladder distension. Sitting the patient upright helps lower blood pressure while the nurse rapidly checks the bladder, bowel and other possible triggers.
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About Orthopaedic Nursing
Covers fractures, dislocations, arthritis, osteoporosis, joint replacement, spinal disorders and complications of immobility. It includes neurovascular assessment, traction and cast care, mobility assistance, pain control, prevention of pressure injuries and deep vein thrombosis, and the difference between compartment syndrome and ordinary postoperative swelling.
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