Question

A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his blood pressure has increased, and that his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client's bed and immediately:

a) Administers nitroglycerin sublingually
b) Administers a beta-blocker
c) Loosens tight clothing and ensures a patent urinary catheter
d) Initiates cardiopulmonary resuscitation (CPR)

Answer 1

In this scenario, the nurse suspects that the client is experiencing autonomic dysreflexia, which is characterized by a sudden increase in blood pressure and a decrease in heart rate. The nurse takes immediate action by elevating the head of the client's bed and loosening tight clothing.

Step-by-step explanation:

In this scenario, the nurse suspects that the client is experiencing autonomic dysreflexia, which is a condition that can occur in individuals with spinal cord injuries. Autonomic dysreflexia is characterized by a sudden increase in blood pressure and a decrease in heart rate. The nurse takes immediate action by elevating the head of the client's bed and loosening tight clothing to promote blood flow and reduce stimulation.

Administering nitroglycerin sublingually is not the appropriate intervention in this case, as nitroglycerin is used to treat angina by relaxing blood vessels and improving blood flow to the heart. Administering a beta-blocker would actually further decrease heart rate, which is not beneficial in autonomic dysreflexia. Initiating cardiopulmonary resuscitation (CPR) is not indicated in this scenario.

It is important for the nurse to assess the client further and identify the cause of autonomic dysreflexia, such as a blocked urinary catheter or other stimuli. Addressing the underlying cause is crucial in managing autonomic dysreflexia.