A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse?
1. to try to calm the patient and make the environment soothing
2. to assess for a full bladder
3. to notify the healthcare provider
4. to prepare the patient for diagnostic radiography
Correct Answer: 2
Autonomic dysreflexia occurs in patients with injury at level T6 or higher and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing environment is fine, but not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.
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