A client with a spinal cord injury at T4 suddenly reports a pounding headache and has severe hypertension. What should the nurse do first?

Question

Accepted Answer

B. Sit the client upright and look for a triggering stimulus — This is autonomic dysreflexia. The first action is to sit the client upright to lower blood pressure, then identify and remove the triggering stimulus such as a full bladder.

Answer

A. Lay the client flat and give fluids

Answer

C. Massage both legs to improve circulation

Answer

D. Apply warm blankets and dim the lights