Difficulty: Medium
Average Score: 80%
Full-length
A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
Correct answer
B
Rationale
The symptoms suggest autonomic dysreflexia, often triggered by a distended bladder or bowel in clients with spinal cord injuries above T6. Assessing and addressing the trigger, such as a distended bladder, is the most appropriate action. Notifying the RN may be necessary but is not the immediate action, so answer A is incorrect. Oxygen and increased IV fluids do not address the cause, so answers C and D are incorrect.