Traumatic Brain and Spinal Cord Injury · NCLEX Exam

A patient with an SCI at T6 develops hypertension with bradycardia, headache, and flushing above the level of injury. What should be the nurse's first response?

  1. Lower the head of the bed and notify the physician
  2. Suspect autonomic dysreflexia, sit the patient upright, remove the noxious stimulus
  3. Administer a rapid intravenous fluid bolus
  4. Apply cold compresses to the patient's feet
Show answer and explanation

Correct answer: Suspect autonomic dysreflexia, sit the patient upright, remove the noxious stimulus

Autonomic dysreflexia occurs in SCI at T6 or higher triggered by noxious stimuli below the injury, requiring immediate intervention to sit upright and remove trigger.

Difficulty: Medium Question 3 of 20

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