Patho Patho #61
When assessing a client with a previous high level spinal cord injury, the nurse places priority on which data?
- BP of 210/110.
This answer is correct because a blood pressure of 210/110 likely indicates that the client is experiencing autonomic dysreflexia.
- RR 14 breaths per minute.
This answer choice is not correct because a respiratory rate of 14 breaths per minute is within normal limits.
- Lungs clear to auscultation.
This answer choice is not correct because lungs that are clear to auscultation indicate a normal breath sounds assessment.
- Hyperactive bowel sounds.
This answer choice is not correct because dangerous hypertension is a more critical finding than hyperactive bowel sounds.
The focus of this question is asking the nurse to identify which assessment finding is most critical in a client with a history of a high level spinal cord injury. Clients with spinal injuries at the level of T6 or higher are at risk for developing autonomic dysreflexia, a potentially life threatening complication. Extreme hypertension is associated with autonomic dysreflexia so a blood pressure of 210/110 is the most critical finding in this client.
Autonomic dysreflexia is a disorder that affects clients with previous high level spinal cord injuries. It may be triggered by abnormalities such as a full bladder or bowel and the result is an overreaction by the sympathetic nervous system. Epinephrine and norepinephrine are released in excess amounts leading to dangerous hypertension, diaphoresis, and headache. A blood pressure of 210/110 likely indicates autonomic dysreflexia and is the most critical finding in this client.
Test Taking Tip
A-B-C; dangerous hypertension is an immediate threat to circulation.