# A 28-year-old patient with a T4 spinal cord injury 3 months ago is admitted with sudden severe pounding headache. BP 218/118, pulse 52, flushing above the level of injury, gooseflesh below, and an indwelling Foley that was last drained 6 hours ago. Which is the nurse's priority first action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372742&lang=en  
> language: en  
> subject: Postsurgical Complications  
> category: PA

## Question

A 28-year-old patient with a T4 spinal cord injury 3 months ago is admitted with sudden severe pounding headache. BP 218/118, pulse 52, flushing above the level of injury, gooseflesh below, and an indwelling Foley that was last drained 6 hours ago. Which is the nurse's priority first action?

## Option

1. Place the patient in an upright sitting position immediately and check the urinary catheter for kinks or obstruction. **✔ Correct answer**
2. Give the patient's regular antihypertensive medication at its usual dose to immediately reduce the severely elevated blood pressure.
3. Cover the patient with a warm blanket to decrease the gooseflesh and promote comfort until the provider gives further orders.
4. Lay the patient flat in bed and immediately contact the healthcare provider to request a stat dose of an antihypertensive.

**Correct answer: 1**

## Explanation

This is autonomic dysreflexia (AD), a life-threatening syndrome in patients with spinal cord injury at or above T6 caused by a noxious stimulus below the level of injury. Findings: severe hypertension, bradycardia, pounding headache, flushing/sweating above the level of injury, pallor and gooseflesh below. The priority is to (1) place the patient upright to lower BP using gravity, (2) immediately remove the trigger — most commonly bladder distention from a kinked or obstructed Foley, fecal impaction, pressure injury, or ingrown nail. If BP does not respond, give a fast-acting antihypertensive (nitrates, hydralazine). Lying flat (choice 4) raises ICP and worsens hypertension. Warming (choice 3) ignores the emergency. Routine antihypertensive (choice 2) is too slow and does not address the trigger.

## In-depth explanation

Autonomic dysreflexia is a life-threatening syndrome in patients with spinal cord injury at or above T6 in which a noxious stimulus below the level of injury triggers massive sympathetic outflow. Hallmarks are severe hypertension, bradycardia, pounding headache, flushing or sweating above the level of injury, and pallor and gooseflesh below. Untreated it risks stroke, MI, and seizure. Common triggers below the level of injury are bladder distention (kinked Foley, urinary retention, UTI) — by far the most common — followed by fecal impaction, pressure injury, ingrown toenail, tight clothing, menstrual cramps, labor, and instrumentation. Initial management priority is to sit the patient upright to lower BP via gravity, remove the trigger (uncatheterize, check Foley patency, gentle bowel disimpaction, inspect skin), and only if SBP remains above 150 after trigger removal give a fast-acting antihypertensive such as nitroglycerin paste, hydralazine, or nifedipine.

## Clinical scenario

A **28-year-old patient** with a **T4 spinal cord injury 3 months ago** presents with **sudden severe pounding headache**. **BP 218/118**, **pulse 52**, **flushing above** the level of injury and **gooseflesh below**, indwelling **Foley last drained 6 hours ago**.

## Key concepts

- **Autonomic Dysreflexia** — Life-threatening syndrome in spinal cord injury at or above T6 from a noxious stimulus below the level of injury that triggers massive sympathetic outflow. Hallmarks: severe hypertension, bradycardia, pounding headache, flushing/sweating above the level of injury, pallor and gooseflesh below. Untreated risks: stroke, MI, seizure.
- **Common Triggers** — Below the level of injury: bladder distention (kinked Foley, full bladder, UTI) — most common; fecal impaction; pressure injury, ingrown toenail, tight clothing; menstrual cramps; labor; instrumentation. Identify and remove the trigger first.
- **Initial Management Priority** — Sit upright to lower BP via gravity; remove the trigger (uncatheterize, check Foley patency, gentle bowel disimpaction, inspect skin); if BP remains >150 systolic after trigger removal, give fast-acting antihypertensive (nitroglycerin paste, hydralazine, nifedipine).

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