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

The patient states having nasal congestion.

The patient's blood pressure becomes elevated.

The patient's bladder becomes distended.

The patient states having a severe headache.

Answer and Explanation

The Correct Answer is C

A. The patient states having nasal congestion. – Incorrect. Nasal congestion is a symptom of autonomic dysreflexia, not a trigger.

B. The patient’s blood pressure becomes elevated. – Incorrect. Hypertension is a symptom of autonomic dysreflexia, not the cause.

C. The patient’s bladder becomes distended. – Correct Answer. Bladder distention is the most common trigger of autonomic dysreflexia, a life-threatening condition causing sudden hypertension, bradycardia, and severe headache. Immediate intervention is needed, such as catheterizing the bladder.

D. The patient states having a severe headache. – Incorrect. A severe headache is a symptom of autonomic dysreflexia, not a cause.

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Correct Answer is A

Explanation

A. Correct. Moving objects prevents injury during a seizure.

B. Incorrect. The patient should be placed on their side to maintain airway patency.

C. Incorrect. Restraining the patient can cause injury.

D. Incorrect. Never insert anything into a seizing patient’s mouth, as it can obstruct the airway or break teeth.

A. Impaired immunity B. Hypoxia C. Fluid retention D. Prolonged bleeding

Correct Answer is B

Explanation

A. Impaired immunity. – Incorrect. While anemia may weaken overall health, hemoglobin levels of 10 g/dL do not significantly affect immune function.

B. Hypoxia. – Correct Answer. Hemoglobin carries oxygen in the blood, and low levels can lead to decreased oxygen delivery to tissues, causing hypoxia.

C. Fluid retention. – Incorrect. Anemia does not directly cause fluid retention.

D. Prolonged bleeding. – Incorrect. While severe anemia can be associated with bleeding disorders, a hemoglobin level of 10 g/dL does not significantly impair clotting.

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

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