A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse,"I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first?

Question

Quizplus · Accepted Answer

The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine if autonomic hyperreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated if autonomic hyperreflexia is ruled out as the cause of the nausea. After checking the BP,the nurse may assess for a fecal impaction using lidocaine jelly to prevent further increased BP.

A Patient Admitted with Dermal Ulcers Who Has a History