Editing Nursing Skills and Procedures – RN Practice Questions (section)

==Question 13==
A client with a T4 spinal cord injury suddenly develops a pounding headache, blood pressure of 196/110 mm Hg, a pulse of 48 beats per minute, flushing of the face, and cool pale skin below the level of injury. Which action should the nurse take '''first'''?
# Place the client in a sitting position with the head of the bed elevated.
# Assess the urinary catheter tubing for kinks or obstruction.
# Administer the prescribed antihypertensive medication.
# Notify the provider of the client's blood pressure.

'''Answer:''' 1 (A). Place the client in a sitting position with the head of the bed elevated.

''Rationale:'' This is autonomic dysreflexia, a hypertensive emergency that can cause stroke or seizure. Raising the head of the bed immediately uses orthostatic pooling to lower blood pressure and takes seconds. The nurse then removes the noxious stimulus, most often a kinked or obstructed catheter, fecal impaction, or restrictive clothing, as in option 2. Option 3 follows if positioning and stimulus removal do not lower the pressure. Option 4 is necessary but not before the two immediate interventions the nurse can perform independently.