The nurse is caring for a client with a T2 spinal cord injury who tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which of the following actions should the nurse take first?
A)Assess for a fecal impaction.
B)Give the prescribed antiemetic.
C)Check the blood pressure (BP).
D)Notify the health care provider.

Question

Quizplus · Accepted Answer

The BP should be assessed immediately in a client with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring.
Notification of the client's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.

The Nurse Is Caring for a Client with a T2