The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse?
a.
Administer acetaminophen as ordered for the headache.
b.
Assess for a kinked urinary catheter and assess for bowel impaction.
c.
Encourage the patient to take slow, deep breaths.
d.
Notify the provider of the patient’s blood pressure.