Difficulty: Medium
Average Score: 93%
Full-length
A client with a T6 injury six 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
Facial flushing and severe hypertension suggest autonomic dysreflexia, often triggered by a distended bladder in spinal cord injury. Assessing and relieving the trigger (B) is priority. Notifying the physician (A), oxygen (C), or fluids (D) is secondary.