Examkin

Soru

Zorluk: OrtaReduction of Risk Potential

A nurse is evaluating a client who sustained a complete spinal cord injury at the T4 level several weeks ago. The client suddenly reports a severe, throbbing headache. The nurse observes profuse diaphoresis on the client's face and neck, and obtains a blood pressure reading of 198/104 mm Hg. Which action must the nurse implement first to reduce the risk of a life-threatening complication?

  1. A
    Palpate the lower abdomen to assess for bladder distention.
  2. Elevate the head of the bed to a high Fowler's position.Cevap
  3. C
    Prepare to administer a prescribed short-acting intravenous antihypertensive.
  4. D
    Place the client in a supine position while removing any restrictive garments.

Cevap

Elevate the head of the bed to a high Fowler's position.
The client is experiencing autonomic dysreflexia, a medical emergency characterized by uncontrolled hypertension in individuals with a spinal cord injury at or above T6. The absolute first action is to elevate the head of the bed to a sitting or high Fowler's position. This utilizes gravity to pool blood in the lower extremities, inducing orthostatic hypotension and immediately lowering the blood pressure, which significantly reduces the imminent risk of a hemorrhagic stroke.

Adım Adım Çözüm

1
Analyze the clinical presentation against the client's history.
The client with a T4 spinal cord injury is exhibiting classic signs of autonomic dysreflexia, characterized by a severe headache, diaphoresis above the injury level, and significant hypertension.
Identifying the syndrome is necessary to anticipate life-threatening risks, such as a cerebrovascular accident.
2
Determine the immediate priority action to mitigate the physiological risk.
The most urgent physiological need is to lower the client's dangerously high blood pressure using orthostatic principles.
Sitting the client upright induces orthostatic hypotension, safely and immediately reducing blood pressure to mitigate the risk of a stroke while the underlying cause is being investigated.

Anahtar Kavram

Autonomic Dysreflexia Priority Interventions
Bu soruyu puanla

Konular

Reduction of Risk Potential

Bu konudan daha fazla soru