A nurse is monitoring a 15-year-old client who is admitted following a motorcycle accident. The tests reveal that the client has a spinal cord injury. Which of the following signs should prompt the nurse to see the RN immediately as it indicates possible autonomic dysreflexia?
Explanation
Answer: A - The nurse caring for a client with a spinal cord injury should watch out for signs of autonomic dysreflexia, which includes an increasing blood pressure, flushing of the face, pupil dilation, bradycardia, nasal stuffiness, throbbing headache, nausea, and piloerection.
