A patient hospitalized following a T4 injury complains of a severe pounding headache and is profusely diaphoretic. The nurse's best intervention is to:
A) Place the patient immediately in a sitting position.
B) Catheterize the patient.
C) Manually disimpact the patient.
D) Administer an analgesic.
Ans: A
Feedback: A severe pounding headache and profuse diaphoresis are symptoms of autonomic dysreflexia. The patient is placed immediately in a sitting position to lower blood pressure. If a urinary catheter is in place, it should be irrigated to be certain it is patent. If a fecal mass is present, a topical anesthetic is inserted 10 to 15 minutes before the mass is removed. Visceral distention or contraction can cause autonomic dysreflexia.
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