A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 . What is the nurse's best first action?
A. Palpate the area over the bladder for distention.
B. Place the client in the Trendelenburg position.
C. Administer oxygen via a nasal cannula.
D. Perform carotid massage.
A
The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified.
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