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NCLEX Question of the Day
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A client with a T4 spinal cord injury suddenly develops severe pounding headache, facial flushing, and profuse sweating above the level of injury. The blood pressure is 210/110 mmHg. What is the nurse's initial action?
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Administer a prescribed PRN analgesic
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Check for bladder distention or bowel impaction
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Notify the healthcare provider immediately
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Correct answer Place the client in a high-Fowler's position
Rationale
The client is exhibiting signs of autonomic dysreflexia (AD), a life-threatening emergency in clients with spinal cord injuries at T6 or above. It is caused by a noxious stimulus (most commonly bladder distention or bowel impaction) below the level of injury, triggering an exaggerated sympathetic response resulting in severe hypertension, headache, flushing, and diaphoresis above the injury level. The initial priority action is to place the client in a high-Fowler's position (sit the client up) to help lower blood pressure via orthostatic effect. Subsequently, the nurse should identify and remove the noxious stimulus (checking for bladder/bowel issues is the next step), and notify the HCP. Administering analgesics does not address the underlying cause or the dangerous hypertension.
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