Difficulty: Medium
Average Score: 78%
Full-length
A client with a C3 spinal cord injury has a headache and nausea. The clientÔÇÖs blood pressure is 170/100 mm Hg. How should the nurse respond initially?
Correct answer
D
Rationale
Headache, nausea, and hypertension in a C3 injury suggest autonomic dysreflexia, often triggered by bladder distension. Palpating the bladder identifies and addresses the cause. Medications and bed positioning are secondary.