A client with a high thoracic spinal cord injury suddenly reports a pounding headache. The nurse observes facial flushing and a markedly elevated blood pressure. Which action should the nurse take first?
1Sit the client upright, loosen constrictive items, and assess the urinary catheter✓ Correct answer
2Place the client flat, elevate both legs, and apply warm blankets for blood pressure support
3Begin digital rectal stimulation immediately while the client remains supine
4Offer oral fluids, lower the room lights, and repeat the blood pressure later
Explanation
The findings indicate autonomic dysreflexia. Sit the client upright to lower cerebral pressure, loosen constrictive items, monitor blood pressure, and quickly search for the trigger beginning with bladder distention or a blocked urinary catheter.
Quick answer Sit the client upright, loosen tight items, and check the urinary catheter. These actions begin lowering the dangerous blood pressure while addressing the most common trigger.
Why this is correct A noxious stimulus below a high spinal cord injury can produce uncontrolled sympathetic vasoconstriction and severe hypertension. Upright positioning uses gravity to reduce pressure, while bladder assessment targets a frequent and rapidly correctable source.
Easy analogy or mental picture Autonomic dysreflexia is like a pressure surge below a blocked control line. Sitting upright opens a pressure-relief path while the nurse searches for the blockage; the analogy does not replace blood-pressure monitoring or emergency medication when needed.
Memory hook High spinal injury plus sudden headache and hypertension means sit up, loosen, and look at the bladder first.
NCLEX decision rule For suspected autonomic dysreflexia, position upright immediately, remove constriction, monitor frequently, and inspect for triggers starting with the urinary system. Escalate and administer ordered rapid-acting antihypertensive therapy if pressure remains dangerously high.
Why the other choices are wrong Lying flat and elevating the legs can worsen hypertension. Rectal stimulation may intensify the episode and follows bladder assessment, while fluids and delayed reassessment do not address a life-threatening pressure surge.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
Clinical Practice Guideline: Bladder Management for Adults with Spinal Cord InjuryConsortium for Spinal Cord Medicine