A client with a T6 spinal cord injury reports a pounding headache. BP is 210/110 mmHg, HR is 48/min, and the face is flushed. What is the nurse’s first action?

Question

Accepted Answer

B. Sit the client upright and loosen restrictive clothing — Autonomic dysreflexia is a life-threatening hypertensive emergency. Sit the client upright to lower BP, loosen clothing, and then remove the triggering stimulus (often bladder/bowel) while notifying the provider.

Answer

A. Lay the client flat to improve perfusion

Answer

C. Give an opioid analgesic for the headache

Answer

D. Apply ice packs to the face