NCLEX PN Exam Practice Test Practice Question
The nurse is caring for a client who has a C6 spinal cord injury. He complains of blurred vision and a severe headache. His blood pressure is 210/140. What action should the nurse take initially?
Correct Answer: A
Rationale: In this scenario, the client’s symptoms—blurred vision, severe headache, and significantly elevated blood pressure—suggest the possibility of autonomic dysreflexia, a condition often seen in individuals with spinal cord injuries above T6. Checking for bladder distention (Option A) is crucial, as it is a common trigger for autonomic dysreflexia.
Placing the client in Trendelenburg position (Option B) is not appropriate; this position can exacerbate hypertension. Administering PRN pain medication (Option C) does not address the underlying cause of the symptoms. Continuing to monitor blood pressure (Option D) is important but should not be the initial action when a potential trigger is present.
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