Nursing Priorities
The priority initial action a nurse should take when a client with quadriplegia experiences autonomic dysreflexia.
What is placing the client in a sitting or high-Fowler's position?
This cranial nerve is responsible for pupillary response to light, and its function can be checked by instructing a client to look at the cardinal fields of gaze.
What is Cranial Nerve III (the oculomotor nerve)?
This procedure is an absolute contraindication in a patient with a basilar skull fracture due to the high risk of entering the cerebral cavity or tissue.
What is nasogastric tube insertion?
A triad of clinical signs—including bradycardia, hypotension with cyanosis, and hypoxia—following a cervical spinal cord injury signals the beginning of this type of shock.
What is neurogenic shock?
This post-procedure complication develops due to a leak of cerebrospinal fluid that depletes the circulating volume and is primarily resolved by increasing fluid intake and laying flat.
What is a spinal headache?
This type of intravenous medication is administered to rapidly reduce brain edema and decrease intracranial pressure.
What is an osmotic diuretic?
A nurse evaluates this specific nerve by observing a client’s ability to smile and frown.
What is Cranial Nerve VII (the facial nerve)?
This type of trauma occurs during the initial impact of the brain against the skull, while its counterpart occurs when the brain hits the opposite side of the skull.
What is a coup injury? (The counterpart is a contrecoup injury.)
This common, preventable complication is triggered by a lack of sympathetic input following a cervical spinal cord injury, requiring the nurse to protect the client from environmental cold
What is hypothermia?
This abnormal posturing characteristic, marked by the flexion of the elbows toward the center of the body and plantar flexion of the legs, indicates lesions of the corticospinal tracts
What is decorticate posturing?
To prevent bacterial translocation and decrease the risk of systemic infection, this intervention should begin within 24 to 48 hours for a patient with increased intracranial pressure.
What is enteral nutrition?
Testing a client's visual acuity checks the function of this specific cranial nerve.
What is Cranial Nerve II (the optic nerve)?
A patient presenting with "the worst headache of their life" who subsequently develops eyelid drooping and a constricted pupil is exhibiting this condition.
What is Horner's syndrome?
This non-invasive intervention is highly encouraged between meals for a client with a T4 spinal cord injury to reduce urinary bacterial counts and prevent UTIs.
What is increasing fluid intake?
Restlessness, irritability, a decreased level of consciousness, and a widening pulse pressure are all classic indicators of this dangerous cranial state.
What is increased intracranial pressure (ICP)?
This priority nursing action must be performed for an unconscious post-cerebral hemorrhage patient who cannot independently maintain a clear airway.
What is suctioning saliva from the patient's mouth?
Having a client stand with their eyes closed and touch their nose evaluates equilibrium, which tests this specific cranial nerve
What is Cranial Nerve VIII (the vestibulocochlear nerve)?
Clear fluid leaking from the ear or nose after a head injury strongly indicates this serious problem, which carries a high risk of meningeal infection.
What is a cerebrospinal fluid (CSF) leak?
This specialized device is used to completely immobilize the cervical spine and head for 8 to 12 weeks during the healing process.
What is a halo fixation device?
An initial, sudden, and severe headache accompanied by a rapid decrease in consciousness typically differentiates this type of cerebrovascular event from an ischemic stroke.
What is a hemorrhagic stroke?