A recently injured (3 months ago) client with a spinal cord injury at T4 to T5 is experiencing a complication. He looks extremely ill. The nurse recognizes this as autonomic dysreflexia (autonomic hyperreflexia)
His BP is 210/108; skin very pale; gooseflesh noted on arms. The priority nursing intervention would be to:
A) Check the mouth/throat for pustules and redness
B) Check the jugular vein for distention
C) Assess calves of legs for redness, warmth, or edema
D) Scan his bladder to make sure it is empty
Ans: D
Feedback:
Autonomic hyperreflexia, an acute episode of exaggerated sympathetic reflex responses that occur in persons with injuries at T6 and above, in which central nervous system (CNS) control of spinal reflexes is lost, does not occur until spinal shock has resolved and autonomic reflexes return. Autonomic dysreflexia is characterized by vasospasm, hypertension ranging from mild to severe, skin pallor, and gooseflesh associated with the piloerector response. In many cases, the dysreflexic response results from a full bladder. There is no indication the client has right-sided heart failure (jugular vein distention); has a DVT (calf redness, warmth, or edema); or has strep throat (pustules and red throat/tonsils).
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