Editing Medical-Surgical Nursing – RN Practice Questions (section)

==Question 4==
A patient with a spinal cord injury at the level of the fourth thoracic vertebra suddenly reports a pounding headache. The blood pressure is 208/112 mm Hg, the pulse is 48 beats per minute, and the face is flushed and diaphoretic while the legs are cool and pale. What should the nurse do first?
# Administer the prescribed as-needed antihypertensive medication.
# Place the patient in a sitting position with the head of the bed elevated.
# Check the indwelling urinary catheter tubing for kinks or obstruction.
# Notify the provider and prepare for transfer to the intensive care unit.

'''Answer:''' Option 2, place the patient in a sitting position with the head of the bed elevated.

''Rationale:'' These findings are autonomic dysreflexia, a life-threatening emergency in injuries at or above the sixth thoracic vertebra. Sitting the patient upright uses orthostatic pooling to lower blood pressure immediately and takes only seconds. Removing the noxious stimulus, most often a distended bladder or impacted bowel, is the next action (option 3), followed by notification (option 4) and medication if pressure remains elevated (option 1). All four actions occur, but positioning is done first because it is immediate and requires no order.