# A 28-year-old client with a T4 spinal cord injury suddenly develops a severe pounding headache, profuse sweating above the injury level, and a blood pressure of 210/110 mm Hg. The nurse identifies these findings as autonomic dysreflexia. After placing the client in a high-Fowler's position and loosening tight clothing, which action should the nurse take next?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=505813&lang=en  
> language: en  
> subject: Physiological Adaptation  
> category: PA

## Question

A 28-year-old client with a T4 spinal cord injury suddenly develops a severe pounding headache, profuse sweating above the injury level, and a blood pressure of 210/110 mm Hg. The nurse identifies these findings as autonomic dysreflexia. After placing the client in a high-Fowler's position and loosening tight clothing, which action should the nurse take next?

## Option

1. Administer the prescribed as-needed hydralazine 10 mg IV push immediately.
2. Apply a cold compress to the client's forehead and provide a dark, quiet environment.
3. Check the indwelling urinary catheter for kinks and perform a bladder scan for distention. **✔ Correct answer**
4. Massage the client's lower extremities to promote venous return and reduce blood pressure.

**Correct answer: 3**

## Explanation

After elevating the head and loosening constrictive clothing, the priority is to identify and relieve the triggering stimulus, most commonly bladder distention. Checking the urinary catheter for kinks and scanning for distention directly addresses this common trigger and can rapidly resolve the episode. Administering hydralazine is reserved for persistent severe hypertension after trigger removal and is not the immediate next step. Applying a cold compress or providing a dark environment does not address the underlying cause and may delay definitive treatment. Massaging the lower extremities is not indicated and could potentially worsen the condition by causing additional noxious stimuli.

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