A nurse is caring for a client who has a T-4 spinal cord injury.
Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

Choice A rationale

Instructing the client to blow their nose should be avoided during epistaxis, as it can dislodge any forming clots, exacerbate bleeding, and potentially increase intracranial pressure temporarily, particularly if associated with hypertension. The primary goal is to promote vasoconstriction and clot formation.

Choice B rationale

Tilting the client's head backward is contraindicated during epistaxis because it can cause blood to flow down the posterior pharynx, leading to swallowing of blood, which can irritate the stomach and induce nausea or vomiting. Aspiration of blood is also a potential risk.

Choice C rationale

Applying ice to the bridge of the client's nose causes local vasoconstriction, which helps to reduce blood flow to the area and promote hemostasis. The cold temperature induces reflex vasoconstriction in the nasal vasculature, thereby helping to slow or stop the bleeding.

Choice D rationale

Moving the client into a high-Fowler's position is beneficial as it reduces venous pressure in the head and neck, thereby decreasing blood flow to the nasal vasculature and minimizing bleeding. Gravity assists in lowering hydrostatic pressure in the affected vessels, facilitating clot formation.

Choice E rationale

Applying direct pressure to the nares (soft part of the nose) for at least 10-15 minutes is a fundamental and highly effective first-line intervention for epistaxis. This direct pressure helps to compress the bleeding vessels, allowing for clot formation and cessation of hemorrhage.

Choice A rationale

Psoriasis is a chronic autoimmune skin condition characterized by red, scaly patches (plaques) with well-defined borders, often on extensor surfaces like elbows and knees. It does not typically manifest as a butterfly-shaped rash on the face, differentiating it from the specified presentation.

Choice B rationale

Eczema (atopic dermatitis) is an inflammatory skin condition presenting with itchy, red, and sometimes weeping or crusted patches. While it can affect the face, its distribution and appearance do not typically form the classic butterfly-shaped malar rash described.

Choice C rationale

Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease characterized by systemic inflammation. A classic dermatological manifestation is the "malar rash" or "butterfly rash" over the cheeks and bridge of the nose, resembling a sunburn, which is highly characteristic of the disease.

Choice D rationale

Acne vulgaris is a common skin condition involving inflammation of hair follicles and sebaceous glands, leading to comedones, papules, pustules, and cysts. It typically affects the face, chest, and back but does not present as a distinct butterfly-shaped erythematous rash.