# Situation: A 30-year-old man with a complete spinal cord injury at the sixth cervical (C6) level from a fall 3 months ago is on a rehabilitation unit. Spinal shock has resolved. His bladder is emptied by intermittent catheterization every 4 hours. His usual blood pressure (BP) is 96/60 mmHg. At 14:00, 30 minutes before his next catheterization, he reports a pounding headache and blurred vision. His face and neck are flushed and sweaty. BP is 150/92 mmHg and heart rate is 54/min. Which is the MOST likely explanation?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630324  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 30-year-old man with a complete spinal cord injury at the sixth cervical (C6) level from a fall 3 months ago is on a rehabilitation unit. Spinal shock has resolved. His bladder is emptied by intermittent catheterization every 4 hours. His usual blood pressure (BP) is 96/60 mmHg.

At 14:00, 30 minutes before his next catheterization, he reports a pounding headache and blurred vision. His face and neck are flushed and sweaty. BP is 150/92 mmHg and heart rate is 54/min. Which is the MOST likely explanation?

## 보기

1. Rising intracranial pressure from an unnoticed head injury
2. Autonomic dysreflexia from a full bladder **✔ 정답**
3. Migraine brought on by the bright lights of the gym
4. Anxiety-related hypertension before his therapy session

**정답: 2**

## 해설

In cord injury at T6 or above, a noxious stimulus below the level, most often a full bladder, triggers a massive sympathetic discharge. A systolic rise of 20 to 40 mmHg or more above baseline is significant, and his 150 mmHg is 54 mmHg above his usual 96 mmHg even though it looks only mildly high. A pounding headache, flushing and sweating above the injury, and reflex bradycardia complete the picture.

## 심화 해설

Why this is autonomic dysreflexia

The patient’s injury is at C6, which is above the T6 neurologic level. After spinal shock resolves, patients with lesions at or above T6 can develop autonomic dysreflexia (AD) when a noxious stimulus below the injury triggers an exaggerated sympathetic response. The most common trigger is bladder overdistension, and this patient is 30 minutes before his next scheduled intermittent catheterization, making a full bladder highly likely [1][2][3].

A systolic blood pressure rise of 20 to 40 mmHg or more above the patient’s baseline is considered significant in AD. His usual BP is 96/60 mmHg, and the current reading of 150/92 mmHg represents a 54 mmHg systolic increase. Even though 150 mmHg may appear only mildly elevated in a general adult, it is a dramatic rise for this individual and meets the threshold for AD.

The clinical picture completes the diagnosis. The pounding headache, flushed and sweaty face and neck, and blurred vision reflect vasodilation and sweating above the injury level, while reflex bradycardia at 54/min is the baroreceptor-mediated vagal response to the sudden hypertension [2]. These findings are classic for AD and do not fit the other options.

| Finding | Autonomic dysreflexia | Intracranial pressure rise | Migraine | Anxiety hypertension |
| --- | --- | --- | --- | --- |
| BP pattern | Sudden rise ≥20–40 mmHg above baseline | Often with widening pulse pressure, bradycardia, altered consciousness | Usually no significant BP elevation | Mild to moderate rise, no reflex bradycardia |
| Heart rate | Reflex bradycardia | Bradycardia possible but with Cushing triad | Normal or slightly increased | Tachycardia more common |
| Skin above injury | Flushed, sweaty | Not characteristic | Pallor or nausea possible | Diaphoresis possible but diffuse |
| Trigger | Bladder or bowel distension below injury | Trauma, mass, hemorrhage | Light, stress, foods | Psychological stress |

Key point! In a patient with SCI at T6 or above, any sudden headache with elevated BP should be treated as AD until proven otherwise. The first nursing action is to sit the patient upright, check the bladder and catheter, and remove the noxious stimulus. Watch out! Do not dismiss a BP of 150/92 mmHg as “not that high” — the comparison must always be made against the patient’s own baseline, not population norms.

The systematic review confirms that neurogenic detrusor overactivity (NDO) is a major trigger for AD, and managing bladder overactivity is a core strategy for preventing recurrent episodes [1]. One source reports that bladder overdistension accounts for approximately 85% of AD cases, underscoring why a full bladder is the most likely explanation here [3].References (research sources)

- [1]Treating neurogenic detrusor overactivity in order to manage autonomic dysreflexia - A systematic review.Meta-analysis/systematic reviewLe BT, Denys P, Joussain C. (2026) · DOI: 10.1016/j.autneu.2026.103454

- [2]Autonomic DysreflexiaResearch articleBilgin Badur N, Winkle MJ, Leslie SW. (2026)

- [3][Autonomic dysreflexia].Research articleKrivoborodov G G, Yefremov N S, Bolotov A D, Gontar A A, Shirin D A. (2025) · DOI: 10.1055/b-0034-81302

## 임상 시나리오

Autonomic Dysreflexia: Immediate Recognition and ActionA life-threatening emergency in SCI at or above T6
In any patient with spinal cord injury at or above T6, a sudden systolic BP rise of 20–40 mmHg or more above baseline is significant. This patient's BP of 150/92 mmHg is 54 mmHg above his usual 96 mmHg, meeting the threshold for autonomic dysreflexia.

The most common trigger is bladder overdistension. This patient is 30 minutes before his next scheduled catheterization, making a full bladder highly likely. Other triggers include bowel impaction, pressure injuries, tight clothing, or urinary tract infection.

Classic findings include pounding headache, flushing and sweating above the injury level, blurred vision, and reflex bradycardia (heart rate 54/min) from baroreceptor-mediated vagal response to sudden hypertension.

CautionImmediately sit the patient upright, check the bladder first, and catheterize if distended. Monitor BP every 2–5 minutes until stabilized. If BP remains elevated after bladder emptying, check for other triggers and administer antihypertensives as ordered. Never ignore a BP that appears only mildly high—it is the rise above baseline that defines the emergency.

## 핵심 개념

- **Autonomic dysreflexia** — Life-threatening exaggerated sympathetic response in SCI at or above T6 triggered by noxious stimuli below the injury, most commonly bladder distension.
- **Spinal shock** — Temporary loss of reflexes and autonomic function below the injury level that resolves over weeks to months.
- **Reflex bradycardia** — Baroreceptor-mediated vagal slowing of heart rate in response to sudden hypertension, a hallmark of autonomic dysreflexia.
- **Intermittent catheterization** — Scheduled bladder emptying technique for neurogenic bladder; missed or delayed catheterization can lead to overdistension.
- **Noxious stimulus** — Painful or irritating trigger below the injury level such as full bladder, bowel impaction, or pressure injury that initiates the AD cascade.

## 같은 주제 문제

- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630316)
- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630317)
- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630318)
- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630319)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630320)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630321)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630322)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630323)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._