A client receiving care for a spinal cord injury complains of a pounding headache, blurred vision, and has a blood pressure of 200/100 mmHg. What is the first action the nurse should take?

Question

Quizplus · Accepted Answer

The client's headache and elevated blood pressure could indicate autonomic dysreflexia, which is a potentially life-threatening emergency that can be triggered by bladder distension. The nurse should check the client's bladder for distension and take steps to relieve it if it is present. Administering pain medication or positioning the client on the left side will not address the underlying cause of the symptoms, and turning off the lights and decreasing noise may be helpful for comfort but will not address the potentially life-threatening situation.

A Client Receiving Care for a Spinal Cord Injury Complains