Question

In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy

rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?
A) Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
B) Place the client into the bed and administer the ordered PRN analgesic
C) Check the client for bladder distention and the client's urinary catheter for kinks
D) Turn the television off and then assist client to use relaxation techniques

Answer 1

The nurse should take the client's vital signs and assessments, including respirations, blood pressure, temperature, and pupillary responses.

Step-by-step explanation:

The nurse should take the client's respirations, blood pressure (BP), temperature, and then pupillary responses next. These vital signs and assessments will help identify any possible underlying medical conditions or causes for the client's symptoms. They can provide important information about the client's overall health and guide further interventions or treatments.