Answered
A home care nurse is caring for an adolescent with a T1 spinal cord injury. The adolescent suddenly becomes flushed, hypertensive, and diaphoretic. Which intervention should the nurse perform first?
A) Place the adolescent in a flat right side-lying position.
B) Place a cool washcloth on the adolescent's forehead and continue to monitor the blood pressure.
C) Implement a standing prescription to empty the bladder with a sterile in and out Foley catheter.
D) Take a full set of vital signs and notify the health care provider.
On May 12, 2024