Difficulty: Medium
Average Score: 95%
Simulated
The nurse assesses the patient with a spinal cord injury at the level C-7 and finds warm, flushed skin with profuse sweating above the level of injury, and pale, cold skin below the level of injury. The patient is bradycardic, but severely hypertensive. What are the priority nursing interventions?
Correct answer
B
Rationale
Symptoms indicate autonomic dysreflexia, requiring assessment for noxious stimuli (e.g., bladder distension) and anticipation of antihypertensives to manage severe hypertension.