A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially?

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Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli, which clients with spinal cord injuries above T6 are unable to feel. Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea. It is essential that the nurse assess for and remove noxious stimuli to prevent a stroke (Option D). Noxious stimuli may include: Bladder distention (eg, obstructed urinary catheter, neurogenic bladder) Fecal impaction Tight clothing (eg, shoelaces, waistbands) (Options A and B) Hypertension, headache, and nausea due to uncontrolled sympathetic activity will resolve once the cause is identified and removed. (Option C) Lowering the head of the bed would increase blood pressure. The head of the bed should be raised to lower the blood pressure. Educational objective: Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli (eg, bladder distention, tight clothing) in clients with spinal cord injuries above T6. Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea. The nurse must immediately identify and remove noxious stimuli to prevent a stroke and resolve symptoms.

A Client with a C3 Spinal Cord Injury Has a Headache