RN Med Surg Neurosensory & Musculoskeletal Exam Questions And Answers (Verified)

RN Med Surg Neurosensory & Musculoskeletal Exam Questions And Answers (Verified) A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes flushing and a blood pressure of 220/110 mm Hg. Which of the following actions should the nurse take first? Elevate the head of the client's bed Explanation: This client is experiencing autonomic dysreflexia and is at risk for cerebral vessel rupture or increased intracranial pressure. Move the client from supine to an upright position. A nurse is caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first? Check the position of the weights and ropes Explanation: The nurse should check the weights and ropes to see what is the cause of the muscles spasms. A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell while at home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to administer? Tissue plasminogen activator