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NCLEX Question of the Day: Spinal Cord Injury Assessment

Osmosis Team
Published on May 12, 2021. Updated on May 11, 2021.

Today's NCLEX-RN® question of the day focuses spinal cord injury assessment.

A client with a history of spinal cord injury (SCI) reports a severe headache and blurred vision. Upon assessment, the nurse notes the following: hypertension, bradycardia, and a flushed face. Which intervention should the nurse implement first?

A. Apply compression stockings

B. Lower the head of the bed

C. Empty the client’s bladder

D. Increase the IV flow rate

Scroll down for the correct answer!


The correct answer to today's NCLEX-RN® Question is...

C. Empty the client’s bladder

Rationale: The client is demonstrating signs of autonomic dysreflexia which is an emergency requiring immediate intervention. Autonomic dysreflexia can be caused by a distended bladder or rectum, urinary tract infection, or other sensory stimulation below the level of the spinal cord lesion. The sensory stimulation causes a massive sympathetic discharge leading to vasoconstriction and hypertension, while baroreceptors in the carotid sinus respond by causing a parasympathetic outflow above the level of the cord lesion, leading to facial flushing and bradycardia.

Major takeaway

One of the main causes of autonomic dysreflexia in clients diagnosed with SCIs is a full bladder, so emptying the bladder is often an effective intervention.

Incorrect answer explanations

A. Apply compression stockings

Rationale: The client is demonstrating signs of autonomic dysreflexia which is an emergency requiring immediate intervention. Application of compression stockings will increase stimulus below the cord lesion and make the situation worse.

B. Lower the head of the bed

Rationale: The client is demonstrating signs of autonomic dysreflexia which is an emergency requiring immediate intervention. Because the client is at risk for a stroke, the head of the bed should be raised to decrease cerebral venous flow.

D. Increase the IV flow rate

Rationale: The client is demonstrating signs of autonomic dysreflexia which is an emergency requiring immediate intervention. Increasing the IV flow rate is not an effective intervention in this case.

Reference

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