When assessing a client with portal hypertension, the nurse should be alert for life threatening indications of

A. Assess for a fecal impaction: Fecal impaction can trigger autonomic dysreflexia in clients with spinal cord injuries, but assessing it is not the first action. Immediate evaluation of vital signs is essential to determine if a hypertensive crisis is occurring. Delaying this could put the client at risk for serious complications.

B. Give the prescribed antiemetic: Administering an antiemetic addresses nausea but does not treat the potentially life-threatening cause. In spinal cord injury, symptoms like headache and nausea may signal autonomic dysreflexia. Treating symptoms without assessing for the underlying cause can be dangerous.

C. Check the blood pressure: Clients with T6 or higher spinal cord injuries are at risk for autonomic dysreflexia, which can present with sudden hypertension, headache, and nausea. Checking blood pressure first identifies a potentially emergent situation. Rapid recognition allows for timely interventions to prevent stroke or other complications.

D. Notify the health care provider: Notification is important but comes after assessing the client’s blood pressure and identifying a potential emergency. Immediate action depends on objective data rather than only reporting symptoms. This ensures the provider receives accurate and timely information.

A. Blood pressure 148/78, pulse 112, respirations 28: Mild increases in blood pressure, pulse, and respirations can be compensatory responses to stress or pain. These changes are concerning but not immediately indicative of life-threatening complications.

B. Blood pressure 156/60, pulse 58, respirations 12: This pattern represents Cushing’s triad—hypertension with widened pulse pressure, bradycardia, and irregular respirations—indicating increased intracranial pressure. It is a neurologic emergency requiring immediate intervention to prevent brain herniation.

C. Blood pressure 130/72, pulse 90, respirations 32: Slightly increased respirations with stable blood pressure and pulse are not as alarming. They may reflect pain, anxiety, or mild hypoxia but are not emergent signs of intracranial pressure elevation.

D. Blood pressure 110/70, pulse 120, respirations 30: This pattern suggests early compensation for hypovolemia or stress. While it requires monitoring, it does not indicate imminent neurologic deterioration like Cushing’s triad.