Question

A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mmHg. Which of the following actions should the nurse take first?

a. Administer an antiemetic.

b. Assist the client to a sitting position.

c. Document the findings in the client's chart.

d. Administer an antihypertensive medication as prescribed.

Answer 1

The nurse should first assist the quadriplegic client with a headache, nausea, facial flushing, and high blood pressure to a sitting position, as these symptoms indicate autonomic dysreflexia, a serious condition requiring immediate intervention to lower blood pressure.

Step-by-step explanation:

The nurse is assessing a client who is quadriplegic with a cervical fracture at C5, reporting a throbbing headache and nausea, facial flushing, and an extremely high blood pressure of 220/110 mmHg. These symptoms are suggestive of autonomic dysreflexia, a potentially life-threatening condition that is commonly triggered by an irritant below the level of the spinal injury. In such a scenario, the first action the nurse should take is to assist the client to a sitting position to help lower blood pressure through the effects of gravity.

The nurse can also look for other potential triggers such as a full bladder or bowel that can cause autonomic dysreflexia and address them promptly. Additional steps will include monitoring the client closely, following established protocols for emergency situations, which may include administering antihypertensive medication if prescribed. Documenting the findings in the patient's chart and possibly administering an antiemetic are also important but are not the immediate priorities in this situation.