A Quadriplegic Patient with a C5 Injury Has Return of Function

question 35

Multiple Choice

A quadriplegic patient with a C5 injury has return of function of the lower motor neurons and is beginning rehabilitation. The patient is in a halo vest. As the nurse prepares to transfer the patient to a wheelchair, the patient complains of a throbbing headache and nausea, and the nurse notes that the patient's face looks flushed. What should the nurse do first?

• A)Check the patient's blood pressure.
• B)Do a digital rectal examination for the presence of an impaction.
• C)Advise the patient that sitting in the wheelchair will help relieve the headache.
• D)Notify the RN or physician immediately of the patient's headache.