The night nurse receives the hand-off report on assigned clients. Which client should the nurse assess first?

Question

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Autonomic dysreflexia (hyperreflexia) can occur in any individual with a spinal cord injury at or above T6. The condition causes an exaggerated sympathetic nervous system response resulting in uncontrolled hypertension. Common triggers include bladder or rectum distention and pressure ulcers. Characteristic manifestations include acute onset of throbbing headache, nausea, and blurred vision; hypertension and bradycardia; and diaphoresis and skin flushing above the level of the injury. It is a medical emergency that requires immediate intervention (eg, bladder catheterization) to remove the precipitating trigger. (Option A) Oliguria (<0.5 mL/kg/hr or <280 mL in 8 hours for an adult of average weight [154 lb or 70 kg]) is an expected finding in a client with kidney injury scheduled for hemodialysis; this client assessment is not the priority. (Option B) Bladder spasms are an expected finding in a client with an indwelling urinary catheter following a prostatectomy. The nurse can administer prescribed analgesic and antispasmodic drugs (eg, Belladonna-opium suppositories, oxybutynin) to alleviate discomfort. However, this client assessment is not the priority. (Option C) Laser lithotripsy breaks down a large stone into small fragments to ease stone elimination. The ureteral stent maintains ureter patency by preventing obstruction caused by edema or stone fragments. Burning on urination and hematuria are common expected side effects associated with this procedure. This client assessment is not the priority. Educational objective: A client with a spinal cord injury at or above T6 is at risk for autonomic dysreflexia, a medical emergency that can lead to hypertensive emergency (eg, stroke, myocardial infarction) and death. Common triggers include bladder or rectum distention and pressure ulcers.

The Night Nurse Receives the Hand-Off Report on Assigned Clients