A client with a spinal cord injury 2 months ago now complains of a pounding headache. The pulse is 64 and the blood pressure is 220/110mmhg. Which of the following action should the nurse take first?

1. A

   Give analgesic as ordered

2. B

   Check for fecal impaction

3. C

   Elevate the client's head and lower the legs

4. D

   Notify the physician

Appeared in: DHS 2018 shift 1st

Explanation

• The client's symptoms are characteristic of Autonomic Dysreflexia (AD), a medical emergency.
• The most immediate threat from AD is a hemorrhagic stroke due to severe hypertension.
• The first priority is to lower the blood pressure as quickly as possible.
• Elevating the head of the bed to a sitting position uses gravity to pool blood in the lower extremities, which provides a rapid reduction in blood pressure.
• This is the fastest, non-pharmacological intervention a nurse can perform independently to mitigate the immediate danger.

Why Other Options Were Wrong

• Option A: Giving an analgesic treats the symptom (headache) but not the life-threatening cause (severe hypertension). Delaying the primary intervention increases the risk of stroke.
• Option B: While checking for and removing the cause (like fecal impaction or a distended bladder) is a crucial step, it is the second priority. The blood pressure must be addressed first to prevent immediate harm.
• Option D: Notifying the physician is necessary, but it is not the first action. The nurse must perform immediate, independent, life-saving interventions first. Delaying action to call the physician could be fatal.

Related Visual

Clinical Relevance

• Nursing practice connection: Knowing Management of Autonomic Dysreflexia helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
• Recognizing Autonomic Dysreflexia is a critical skill for nurses caring for patients with spinal cord injuries above T6.
• The nurse's rapid and correct initial response can prevent catastrophic outcomes like stroke, seizure, or myocardial infarction.
• What if? If the client with a spinal cord injury was instead complaining of lightheadedness and had a blood pressure of 80/50 mmHg, the correct first action would be to lay them flat and possibly elevate their legs to treat orthostatic hypotension, the opposite of the intervention for AD.

How to Approach the Question

• First, analyze the patient's clinical presentation: a history of spinal cord injury, a pounding headache, extremely high blood pressure (220/110), and a normal to slow pulse (64).
• Recognize that this specific cluster of symptoms points directly to the diagnosis of Autonomic Dysreflexia (AD).
• Understand that AD is a medical emergency where the primary danger is severe hypertension.
• The question asks for the 'first' action. In priority-based questions, always address the most immediate life-threatening problem.
• Evaluate the options based on which one most directly and quickly addresses the severe hypertension.
• Eliminate options that treat symptoms (analgesic), are secondary actions (checking for impaction), or delay immediate care (notifying physician before acting).

Concept Tested & Keywords

• Concept Tested: Management of Autonomic Dysreflexia
• Stem keywords: spinal cord injury, pounding headache, pulse 64, blood pressure 220/110mmhg
• Lead-in keywords: first
• Clinical cues: The combination of a high-level spinal cord injury, severe hypertension, pounding headache, and bradycardia are classic signs of Autonomic Dysreflexia.

Question ID

QHWHHnfFHAZ5Fi9-ZgOGvL

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 pp. 102-104, 103-105

E6 Nelson Textbook of Pediatrics(2024) — Volume 2 p. 2199-2201