Examkin

Question

Difficulty: Very hardPhysiological Adaptation

A practical nurse is providing care for a client who sustained a T3 spinal cord injury two months ago. The client suddenly reports a severe, pounding headache and exhibits profuse diaphoresis and facial flushing. Arrange the following nursing actions in the correct priority sequence.

  1. 1Place the client in a high Fowler's position.
  2. 2Obtain the client's current blood pressure reading.
  3. 3Inspect the indwelling urinary catheter system for kinks.
  4. 4Notify the supervising registered nurse of the assessment findings.

Answer

The correct sequence is to first position the client in high Fowler's, then measure the blood pressure, followed by checking the urinary catheter, and finally notifying the registered nurse.
In the event of autonomic dysreflexia, the primary goal is to prevent a catastrophic hypertensive stroke. Elevating the head of the bed immediately lowers blood pressure through orthostasis. Once the client is safe, confirming the hypertension via a blood pressure check guides further care. The nurse then seeks to eliminate the most common cause (bladder distention) by checking the catheter. Finally, escalating to the RN ensures advanced medical intervention if the crisis persists.

Step-by-Step Solution

1
Place the client in a high Fowler's position.
The client is sitting upright, utilizing gravity to induce orthostatic changes.
This is the most critical and rapid independent action to lower intracranial pressure and blood pressure, reducing the immediate risk of a cerebrovascular accident.
2
Obtain the client's current blood pressure reading.
The severity of the hypertensive crisis is accurately quantified.
Measuring the blood pressure confirms the suspected autonomic dysreflexia and provides necessary clinical data before proceeding to investigate the trigger.
3
Inspect the indwelling urinary catheter system for kinks.
A potential noxious stimulus (bladder distention) is identified and resolved.
A full bladder or obstructed catheter is the leading cause of autonomic dysreflexia; removing this stimulus often resolves the crisis.
4
Notify the supervising registered nurse of the assessment findings.
The RN is made aware of the acute physiological alteration and the interventions performed.
The RN coordinates further pharmacological therapy if conservative nursing measures fail to stabilize the client's blood pressure.

Key Concept

Prioritization of interventions for autonomic dysreflexia in clients with high-level spinal cord injuries.
Estimated Time:2m 0s
Rate this question

Topics

Physiological Adaptation

More questions from this topic