NCLEX-RNReduction of Risk PotentialHard
A client with a spinal cord injury at T6 reports a sudden severe pounding headache. Assessment reveals blood pressure 210/120 mmHg, heart rate 48 beats/min, and flushing above the level of injury. What should the nurse do first?
- AAdminister a PRN dose of an antihypertensive medication
- BLower the head of the bed to a flat position
- CCheck the urinary catheter for kinks or bladder distension
- DNotify the provider and wait for further orders
Show answer & explanationAnswer & explanation
Correct answer: C. Check the urinary catheter for kinks or bladder distension
These findings indicate autonomic dysreflexia, a life-threatening emergency triggered by a noxious stimulus below the level of injury—most commonly bladder distension. The nurse's first action is to sit the client up and check for and relieve the underlying cause, such as a kinked catheter or full bladder, before giving medication.
Why the other options are wrong
- A. Antihypertensives may be needed but only after identifying and removing the triggering stimulus.
- B. The head of bed should be raised, not lowered, to help decrease blood pressure while the cause is investigated.
- D. Waiting for orders delays urgent care in a hypertensive emergency.
Autonomic Dysreflexia
A life-threatening sympathetic nervous system response in spinal cord injury clients (T6 or above) triggered by a noxious stimulus below the injury level.
- Common triggers: bladder distension, constipation, tight clothing
- Signs: severe hypertension, bradycardia, pounding headache, flushing above injury
- First action: sit client upright, then find and remove the triggering stimulus
Memory trick: 'Bladder first, BP will burst' — always check catheter/bladder first.