46. What should a nurse watch for in a client with autonomic dysreflexia following a cervical spinal cord injury?
46. What should a nurse watch for in a client with autonomic dysreflexia following a cervical spinal cord injury?
Test-Taking Tip
Look for contradictory options—hypo-or hyper-. Know the effect of the autonomic system on vital signs.
Content Area: Adult Health, Neurological; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
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Answer 1 is correct because there is a sudden onset of severe hypertension (300 mm Hg systolic), headache, and diaphoresis from some stimulus such as a distended bladder or fecal impaction. Answer 2 is incorrect because the client experiences severe hypertension. Answer 3 is incorrect because the pulse is usually bradycardic. Answer 4 is incorrect because the Cheyne-Stokes pattern is associated with abnormal CO2-O2 tensions in the blood or certain neurological conditions.
