a question about neuro and musculoskeletal

[neurontin]

a client with a quadriplegic secondary to a cervical fracture at vertebral level C5 has a headache, nausea, facial flushing, and BP 220/110. which action the nurse do first?

a. call a doctor

b. elevate the HOB

c. determine if the client has a fecal impaction

d. check the bladder for distention

Which one is the answer? your rationale please... Thanks in advance!

[MyLuckyDay365]

I pick up 2.

[FamuNurse11]

I choose B;sounds like S/S of Autonomic Dysreflexia, you need to is elevate the head of the bed first( reduces BP and allows for full lung expansion). You can rule out C&D because this is what causes AD and call the physician after you had done something. :)

[FlyingScot, RN]

What does your textbook say?

[MyLuckyDay365]

patient has headache, nausea, facial flushing, and BP 220/110 which is a complication of spinal cord injury:

1.please pt in setting position.

2.give antihypertensive medication.

3.check bowel

[shescoolie]

b. these are classic symptoms of autonomic dysreflexia. The first action is ALWAYS to raise the HOB. Look up the disease process for more info :)

[Musvette,BSN,RN]

a client with a quadriplegic secondary to a cervical fracture at vertebral level C5 has a headache, nausea, facial flushing, and BP 220/110. which action the nurse do first?

a. call a doctor

b. elevate the HOB

c. determine if the client has a fecal impaction

d. check the bladder for distention

Which one is the answer? your rationale please... Thanks in advance!

b. elevate the head of the bed, this action lowers the blood pressure and prevents rupture of artery in the brain which can be very fatal during the crisis.

hope this helps.

[caliotter3]

Look up autonomic dysreflexia in your text.

[neurontin]

thank you so much for the replies!

kudos to appreciate your assistance.

you are absolutely right. the answer is b because when a pt has autonomic dysreflexia, the first intervention is to place pt in sitting position to prevent the increasing bp.

[FlyingScot, RN]

So other than the correct answer to your homework question tell us what you've learned about autonomic dysreflexia