NCLEX-RNPhysiological AdaptationMedium
A client with a T4 spinal cord injury reports a sudden severe pounding headache. Assessment reveals blood pressure 210/122 mmHg, heart rate 48/min, and flushing above the level of injury. Which action should the nurse take first?
- ANotify the provider immediately and await orders
- BCheck for bladder distention and a kinked urinary catheter
- CPlace the client in a supine position
- DAdminister the prescribed antihypertensive medication
Show answer & explanationAnswer & explanation
Correct answer: B. Check for bladder distention and a kinked urinary catheter
These findings indicate autonomic dysreflexia, a life-threatening emergency in clients with spinal cord injury at T6 or above, most commonly triggered by bladder distention. The nurse should first identify and remove the noxious stimulus, such as a distended bladder or kinked catheter, before administering medications.
Why the other options are wrong
- A. Waiting for provider orders delays urgent removal of the causative stimulus in this emergency.
- C. The client should be placed upright (sitting), not supine, to help lower blood pressure through orthostatic effect.
- D. Antihypertensives are given only if the stimulus cannot be removed or blood pressure remains critically high after removing the trigger.
Autonomic Dysreflexia
A life-threatening syndrome in spinal cord injury above T6 caused by an unchecked sympathetic response to a noxious stimulus below the injury level, producing severe hypertension and bradycardia.
- Most common trigger: bladder distention (kinked catheter, UTI)
- First action: identify and remove the stimulus, sit client upright
- Untreated can cause stroke, seizure, or death
Memory trick: Full bladder, blown-up blood pressure—empty it first