following morning care, a client with a c5 sp...
following morning care, a client with a c5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. which intervention should the nurse implement first?\na) assess the clients blood pressures every 15 minutes.\nb) relieve any kinks or obstruction in the clients foley tubing.\nc) teach the client to recognize symptoms of dysreflexia.\nd) administer a prescribed prn dose of hydralazine.
Answer
# Brief Explanations:
The client with a C5 spinal - cord injury is likely experiencing autonomic dysreflexia, a medical emergency. The first step is to relieve any potential causes like kinks or obstructions in the Foley tubing as it can be a common trigger. Assessing blood pressure is important but not the first - step. Teaching about symptoms is not an immediate intervention. Administering medication is done after trying to relieve the cause.
# Answer:
B) Relieve any kinks or obstruction in the client's Foley tubing