Difficulty: Medium
Average Score: 81%
Simulated
Passage / Scenario
A client with quadriplegia from a spinal cord injury, reporting a severe headache with a blood pressure of 210/108 mm Hg, suspected of autonomic dysreflexia.A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?
Correct answer
A
Rationale
The correct answer is A: Assess the client for bladder distention. Autonomic dysreflexia is a medical emergency in clients with spinal cord injuries, characterized by a sudden increase in blood pressure. Bladder distention is a common trigger for autonomic dysreflexia in these clients. By assessing for bladder distention first, the nurse can address the root cause of the autonomic dysreflexia and prevent further complications. Choices B, C, and D are incorrect as laying the client flat, obtaining heart rate, or administering a nitrate antihypertensive would not address the underlying cause of autonomic dysreflexia.