Question

Following morning care, a client with a C5 spinal cord injury who is sitting in a wheelchair becomes flushed and complaints of a headache. Which intervention should the nurse implement first?

a. Teach the client to recognize symptoms of dysreflexia
b. Relieve any kinks or obstruction in the client's Foley tubing
c. Administer or prescribe PRN dose of hydralazine
d. Assess the client's blood pressures every 15 minutes

Answer 1

In this situation, the nurse should first relieve any kinks or obstructions in the client's Foley tubing. This can help address the symptoms of increased blood pressure in a client with a C5 spinal cord injury. Monitoring the client's blood pressure is also important in providing ongoing care.

Step-by-step explanation:

In this situation, the nurse should implement intervention b. Relieve any kinks or obstruction in the client's Foley tubing first.

Flushed skin and headache are symptoms of increased blood pressure, which can occur in a client with a C5 spinal cord injury experiencing dysreflexia. However, before administering any medications, it is important to assess for and relieve any potential kinks or obstructions in the client's Foley tubing, as this could be causing the increased blood pressure. Addressing this issue first helps ensure the client's safety and prevents further complications.

Once the kinks or obstructions are relieved, the nurse should then implement intervention d. Assess the client's blood pressures every 15 minutes to monitor for any changes and provide appropriate care.