A patient with a spinal cord injury at T3-T4 experiences a sudden increase in BP and has cool, pale, gooseflesh skin on the lower extremities. Which action does the nurse perform while awaiting physician orders? (Select all that apply.)

Question

Quizplus · Accepted Answer

The patient is likely experiencing autonomic dysreflexia, a condition common in individuals with spinal cord injuries above T6. The symptoms include a sudden increase in blood pressure and changes in skin condition. The nurse should monitor BP frequently (A) to track changes and intervene as necessary. Ensuring the indwelling catheter is patent (D) is crucial because a full bladder is a common trigger for autonomic dysreflexia. Performing a rectal examination (E) is also important to check for fecal impaction, another potential trigger. Placing the patient in a supine position (B) could worsen the hypertension, and while elastic stockings (C) might help with circulation, they do not address the immediate causes of autonomic dysreflexia.

A Patient with a Spinal Cord Injury at T3-T4 Experiences