NCLEX-RN

Category - Reduction of Risk

A nurse is caring for a client diagnosed with a spinal cord injury. The occurrence of which symptom suggests that the client is experiencing autonomic dysreflexia?
  1. A throbbing headache
  2. Hunger
  3. Pallor of the face
  4. Decreased blood pressure
Explanation
Answer - A - Autonomic dysreflexia, also known as hyperreflexia, is a medical emergency characterized by abrupt onset of extremely high blood pressure. A client with autonomic dysreflexia experiences throbbing headache, profuse sweating above the level of lesion, flushing of the skin, and nasal congestion. Autonomic dysreflexia is caused by an irritating stimulus below the level of spinal cord injury, such as bladder distension, bowel compaction, contact with sharp objects, constrictive clothing and pain.
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