A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report about?

1. A

   Dizziness and tachypnea

2. B

   Circumoral pallor and light-headedness

3. C

   Headache and facial flushing

4. D

   Pallor and itching of the face and neck

Appeared in: NORCET -4 , 2023

Explanation

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• Headache and facial flushing are classic signs of autonomic dysreflexia (AD), a life-threatening emergency common in spinal cord injuries (SCI) at or above the T6 level.
• A noxious stimulus below the injury (like a full bladder) triggers an uncontrolled sympathetic response, causing severe hypertension which results in a pounding headache.
• The body attempts to compensate via the parasympathetic system above the injury, causing vasodilation. This leads to flushing of the skin on the face and neck, along with profuse sweating and nasal congestion.
• A C-4 injury is a high cervical injury, placing the client at significant risk for this complication.

Why Other Options Were Wrong

• Option A: Tachypnea (rapid breathing) is not a characteristic sign of AD. Instead, bradycardia (a slow heart rate) is the typical cardiac response due to vagal nerve stimulation attempting to counteract the severe hypertension.
• Option B: Circumoral pallor (paleness around the mouth) is incorrect. The face experiences vasodilation and flushing, not pallor, in AD. Pallor is a sign of vasoconstriction, which occurs below the level of the injury.
• Option D: Pallor of the face and neck is incorrect for the same reason as the other distractors. Flushing occurs above the level of injury. Pallor, coolness, and goosebumps (piloerection) are expected below the level of the C-4 injury.

Related Visual

• Visual 1: Diagram: Pathophysiology of Autonomic Dysreflexia. This visual should illustrate a spinal cord injury above T6, a stimulus below the injury, and the resulting opposite effects: vasoconstriction/hypertension below the injury and vasodilation/bradycardia above it, with corresponding symptoms listed for each area.

Clinical Relevance

• Nursing practice connection: Use the key finding related to Signs and Symptoms of Autonomic Dysreflexia to guide bedside assessment, documentation, and the next nursing action.
• Recognizing AD is a critical nursing responsibility as it is a medical emergency. Uncontrolled hypertension can lead to seizures, retinal hemorrhage, stroke, or myocardial infarction.
• The first and most crucial nursing action is to immediately sit the patient upright (elevate the head of the bed to 90 degrees). This uses gravity to help lower blood pressure while the cause is being investigated.
• Patient and family education is paramount for clients being discharged. They must know the triggers (full bladder, bowel impaction, tight clothing) and the key symptoms (pounding headache, sweating) to report immediately.

How to Approach the Question

• First, identify the core concepts in the question: a client with a C-4 injury and the risk of autonomic dysreflexia (AD).
• Recall that AD is a major complication for spinal cord injuries at or above the T6 level. A C-4 injury is a high-level injury, so the risk is significant.
• Access your knowledge of the pathophysiology of AD. Remember it involves a split response: an uncontrolled sympathetic reaction below the injury and a compensatory parasympathetic reaction above it.
• List the signs for each area. Below injury: vasoconstriction (cool, pale skin). Above injury: vasodilation (headache, flushing, sweating) and bradycardia.
• Evaluate each option against the signs that occur above the level of a C-4 injury, as these are the most prominent and reported symptoms.
• Select the option that correctly pairs two of the classic 'above the injury' signs.

Concept Tested & Keywords

• Concept Tested: Signs and Symptoms of Autonomic Dysreflexia
• Stem keywords: C-4 injury, autonomic dysreflexia, assess, report
• Lead-in keywords: assess for and report about
• Clinical cues: Patient with C-4 injury is at risk for autonomic dysreflexia because the injury is above the T6 level.
• Negative lead-in flag: false

Question ID

QIgK_RPOZOBC1AczHBqSG2

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