If the nurse suspects a spinal cord injury, the patient has developed autonomic dysreflexia. Which of the following assessments would confirm this complication? Select all that apply
A)
BP 180/98
B)
Skin covered with macular rash
C)
Pulse rate 49
D)
Complains of a pounding headache
E)
Cold, cyanotic lower legs
Ans:
A, C, D
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Autonomic dysreflexia represents an acute episode of exaggerated sympathetic reflex responses that occur in people with injuries at T6 and above, in which CNS control of spinal reflexes is lost. It is characterized by hypertension (BP 180/98), skin pallor, vagal slowing of the heart rate (pulse 49), and headache ranging from dull to severe and pounding.
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