A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse’s highest priority?

In a patient with a spinal cord injury at or above T6, sudden severe headache and nausea are hallmark signs of autonomic dysreflexia, a life-threatening emergency caused by an exaggerated sympathetic response to noxious stimuli (such as bladder distention, fecal impaction, or skin irritation). The nurse’s first action is to check the patient’s blood pressure to confirm the diagnosis, since autonomic dysreflexia results in severe hypertension.

Rationale for correct answer:
3. Take the patient’s blood pressure. Confirms whether the symptoms are due to autonomic dysreflexia by detecting dangerous hypertension, which requires immediate intervention.

Rationale for incorrect answers:
1. Call the physician. Contacting the provider is important but not the first action—the nurse must first assess the patient’s BP to confirm the condition.
2. Check the patient’s temperature. Headache and nausea are not early signs of infection in this context; checking temperature delays recognition of a true emergency.
4. Elevate the head of the bed to 90 degrees. This is an essential intervention to lower blood pressure, but assessment (BP check) must be done first to confirm the cause of symptoms.

Take-home points:

• Autonomic dysreflexia presents with severe headache, nausea, flushing, bradycardia, and hypertension in SCI patients at or above T6.
• First priority is to check blood pressure to confirm the condition.
• Once confirmed, the nurse elevates the HOB, removes noxious stimuli, and notifies the physician.

Early surgical intervention is indicated when there is continued compression of the spinal cord, which can worsen neurological deficits. Prompt decompression helps prevent permanent damage, reduce inflammation, and improve the potential for neurological recovery. Timing of surgery is critical to minimize secondary injury and optimize functional outcomes.

Rationale for correct answer:
4. Evidence of continued compression of the cord is apparent. Ongoing compression can exacerbate ischemia and necrosis of spinal tissue. Surgical decompression relieves pressure on the cord, limiting further neurologic compromise and improving recovery potential. Early identification and intervention are essential in preventing irreversible deficits.

Rationale for incorrect answers:
1. There is incomplete cord lesion involvement. While incomplete lesions have better prognosis, this alone does not mandate immediate surgery.
2. The ligaments that support the spine are torn. Ligament injury may require stabilization but is not the primary indicator for urgent decompression.
3. A high cervical injury causes loss of respiratory function. Respiratory compromise is managed supportively; surgical intervention is not indicated solely for loss of function unless compression is present.

Take-home points:

• Continued cord compression is a key indication for early spinal surgery.
• Early decompression reduces secondary injury and improves neurological outcomes.
• Not all spinal injuries require immediate surgery; assessment of compression and stability guides intervention.