A client who was admitted to the neurology unit has injuries above T6. A urinary catheter is in place. After the morning care, the client begins to complain of severe headache. Physical examination reveals flushing of face and neck, bradycardia, hypertension, dilated pupils, and piloerection. Which of the following is an appropriate intervention for the client?
Explanation
Answer: C - The most appropriate intervention is to check for kinks in the urinary tubing. A client with injuries above T6 is at risk for autonomic dysreflexia, which is manifested by flushing of face and neck, bradycardia, hypertension, dilated pupils, and piloerection. Autonomic dysreflexia is commonly caused by bladder distention and impacted rectum. The client should be in high-Fowler’s position. Vital signs are checked every 15 minutes.
