The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache.The nurse assesses a blood pressure of 180/90 mm Hg,heart rate 60 beats/min,respirations 24 breaths/min,and 50 mL of urine via indwelling urinary catheter for the past 4 hours.What is the best action by the nurse?
A) Administer acetaminophen as ordered for the headache.
B) Assess for a kinked urinary catheter and assess for bowel impaction.
C) Encourage the patient to take slow, deep breaths.
D) Notify the physician of the patient's blood pressure.

Question

Quizplus · Accepted Answer

Autonomic dysreflexia,characterized by an exaggerated response of the sympathetic nervous system can be triggered by a variety of stimuli,including a kinked indwelling catheter,which would result in bladder distention.Other causes that should be ruled out prior to pharmacological intervention include fecal impaction.Treating the patient for a headache will not resolve symptoms of autonomic dysreflexia.Treatment must focus on identifying the underlying cause.Slow deep breathes will not correct the underlying problem.Assessing for underlying causes of autonomic dysreflexia should precede contacting the physician.

The Nurse Is Caring for a Patient from a Rehabilitation