A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic. Which priority interventions should the nurse perform? Select all that apply.

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Clients with a high (T6 or above) spinal cord injury are at risk for autonomic dysreflexia (autonomic hyperreflexia). It is an uncompensated sympathetic nervous system stimulation. Classic signs include hypertension (up to 300 mm Hg systolic), throbbing headache, diaphoresis above the level of injury, bradycardia (30-40/min), piloerection ("goose bumps"), flushing, and nausea. This is a life-threatening condition that requires immediate intervention to prevent complications (eg, hypertensive stroke, seizures). Clients with a spinal cord injury should have their blood pressure checked when they report a headache (Option C). The most common cause of autonomic dysreflexia is bladder irritation due to distention. The client needs to be catheterized or the possibility of a kink in the existing catheter must be assessed (Option B). Bowel impaction can also be a cause; a digital rectal examination should be performed. Constrictive clothing should be removed to decrease skin stimulation (Option E). The primary health care provider should be notified. An alpha-adrenergic blocker or an arteriolar vasodilator (eg, nifedipine) may be prescribed. (Option A) Headaches associated with autonomic dysreflexia are typically due to severe hypertension and often resolve after blood pressure has been treated. (Option D) The client should have the head of the bed elevated 45 degrees or high Fowler's to lower blood pressure. The Sims' position is flat and side-lying. Educational objective: Autonomic dysreflexia is a life-threatening condition in a client with high spinal cord injury. Classic signs/symptoms include severe hypertension, throbbing headache, diaphoresis, bradycardia, flushing, and piloerection. Emergency treatment includes correcting the cause (check bowel or bladder distention), removing tight clothing, and raising the head of the bed.

A Client with a T4 Spinal Cord Injury Has a Severe