Question

The nurse is caring for a patient with a C7 spinal cord injury who develops bradycardia, hypertension, and

sweating. Which intervention should the nurse perform first?
A. Palpating the patient's bladder
B. Lying the patient flat in bed
C. Covering the patient with a blanket
D. Performing a rectal examination

Answer 1

The nurse should first palpate the patient's bladder to address potential autonomic dysreflexia, which is a serious condition that can occur in patients with spinal cord injuries.

Step-by-step explanation:

The nurse should first palpate the patient's bladder. These symptoms suggest the patient may be experiencing autonomic dysreflexia, a potentially life-threatening condition common in patients with spinal cord injuries at T6 or above. The trigger is often a full bladder, which the patient might not sense due to the injury.

The nurse’s initial step should involve checking for bladder distension, followed by measures to relieve potential triggers such as bladder catheterization or management of bowel impaction. Immediate intervention is crucial to prevent severe complications like a stroke. Patients with spinal cord injuries should have regular monitoring and preventive care to manage their risk of autonomic dysreflexia.