The nurse receives the assigned clients for today on a neurology unit. The nurse should check on which client first?

Question

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Autonomic dysreflexia (autonomic hyperreflexia) is a massive, uncompensated cardiovascular reaction by the sympathetic nervous system (SNS) in a spinal injury at T6 or higher. Due to the injury, the parasympathetic nervous system cannot counteract the SNS stimulation below the injury. Classic triggers are distended bladder or rectum. Classic manifestations include severe hypertension, throbbing headache, marked diaphoresis above the level of injury, bradycardia, piloerection (goose bumps), and flushing. This is an emergency condition requiring immediate intervention. Management includes raising the head of the bed and then treating the cause. (Option A) The Glasgow Coma Scale (GCS) is an objective scale used to monitor alertness/mental functioning in an acute head injury. The best score is 15, and the worst is 3. This client has an improving trend and is not a priority. (Option B) Myasthenia gravis is an autoimmune disease manifesting mainly as muscle weakness and ptosis. The muscle weakness increases with activity, and by the end of the day, ptosis is present. These are expected findings for this condition, and so this client is not a priority. However, clients with myasthenic crisis can have respiratory failure, which, if it occurs, would be a priority. (Option D) Transverse myelitis (spinal cord inflammation) usually results from a recent viral infection. Classic symptoms include paralysis, urinary retention, and bowel incontinence. Some clients recover, but many have permanent disability. Normal muscle strength is 5 on a scale of 0-5. Weakened muscle strength (2+ means only able to move laterally, not able to lift up against gravity) would be an expected finding. Educational objective: Autonomic dysreflexia in a client with a spinal cord injury is a priority and requires emergency intervention. Classic triggers are distended bladder or rectum. Management includes raising the head of the bed and then treating the cause (eg, Foley catheter kinks).

The Nurse Receives the Assigned Clients for Today on a Neurology