Editing Anatomy and Physiology – RN Practice Questions (section)

==Question 3==
A patient with a spinal cord injury at the T4 level suddenly reports a pounding headache. The nurse finds a blood pressure of 196/104 mmHg, a heart rate of 48 beats per minute, flushing of the face, and cool pale skin below the level of injury. What is the nurse's '''first''' action?
# Administer the prescribed as-needed antihypertensive medication.
# Place the patient in a sitting position with the head of the bed elevated.
# Palpate the bladder and check the urinary catheter for kinks.
# Notify the health care provider of the change in condition.

'''Answer:''' 2 (B). Place the patient in a sitting position with the head of the bed elevated.

''Rationale:'' This is autonomic dysreflexia, an exaggerated sympathetic discharge triggered by a noxious stimulus below an injury at or above T6. Sitting the patient upright uses gravity to produce an immediate orthostatic drop in blood pressure and is the fastest intervention to reduce the risk of stroke and seizure. Only after upright positioning does the nurse look for and remove the trigger, most often a distended bladder or fecal impaction, which makes option 3 the correct second action. Option 1 may be needed if the pressure does not fall once the stimulus is removed, but medication is not the first step. Option 4 is appropriate but does not lower the pressure now.