Question

A patient with a history of a T2 spinal cord tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first?

a. Notify the patient's health care provider.
b. Check the blood pressure (BP).
c. Give the ordered antiemetic.
d. Assess for a fecal impaction.

Answer 1

The nurse should first check the blood pressure (BP). Autonomic dysreflexia, a potentially life-threatening condition, can cause a sudden and severe increase in blood pressure. By checking the patient's blood pressure, the nurse can assess the severity of the situation and take appropriate action to manage the patient's symptoms.

Step-by-step explanation:

The nurse should first b. Check the blood pressure (BP). A patient with a history of a T2 spinal cord injury who complains of a throbbing headache and feeling sick to their stomach may be experiencing autonomic dysreflexia, a potentially life-threatening condition. Autonomic dysreflexia is characterized by a sudden and severe increase in blood pressure, which can lead to a stroke or other serious complications. By checking the patient's blood pressure, the nurse can assess the severity of the situation and take appropriate action to manage the patient's symptoms and prevent further complications. After checking the blood pressure, the nurse should then take appropriate steps to notify the patient's healthcare provider and provide further care as necessary. This may include administering an ordered antiemetic, assessing for other potential complications such as a fecal impaction, and addressing any other concerns or symptoms the patient may be experiencing.