GoodNurse free practice
NCLEX Question of the Day
Review the question, check the correct answer, and read the rationale before tomorrow's prompt arrives.
A nurse is caring for a client with a C6 spinal cord injury who suddenly develops severe headache, flushing above the level of injury, sweating, and blood pressure of 190/110 mmHg. What is the nurse's priority action?
-
Administer prescribed analgesic for headache.
-
Notify the healthcare provider.
-
Correct answer Sit the client upright immediately.
-
Check for bladder distension or bowel impaction.
Rationale
The client is exhibiting classic signs and symptoms of autonomic dysreflexia (AD), a life-threatening emergency in clients with spinal cord injuries at T6 or above. It is triggered by a noxious stimulus below the level of injury (e.g., full bladder, impacted bowel). The hypertension is severe and can lead to stroke or seizure. The priority nursing action is to immediately sit the client upright (high Fowler's position) with legs dependent. This uses gravity to help lower blood pressure.
After positioning the client, the nurse should then quickly assess for and remove the triggering stimulus (e.g., check for kinked catheter tubing, assess for bladder distension, check for bowel impaction). Administering an analgesic addresses a symptom but not the underlying cause or the dangerous hypertension. Notifying the provider is essential, but immediate positioning and assessment/removal of the trigger are the first steps to manage the crisis.
GoodNurse AI
Want to talk through why the other options are wrong? Sign up for GoodNurse to ask follow-up questions and get a guided explanation.
Free daily practice
Get the next question.
One NCLEX-style prompt, answer, and rationale in your inbox every morning. No account needed.
Free NCLEX practice. Unsubscribe anytime.