Answer: Today's NCLEX Question of the Day
The answer is B) Raise the head of the bed to a sitting position.
This is autonomic dysreflexia, a medical emergency in clients with spinal cord injuries at T6 or above. A trigger below the injury (often a full bladder, constipation, or tight clothing) sets off a dangerous spike in blood pressure. Sitting the client up right away uses gravity to help lower the blood pressure, so it comes first.
Why not the others: D, finding the cause (bladder, bowel, skin), is the very next step, but positioning is faster and protects the client first. A, medication, is used if BP stays high after the position change and removing the trigger. C, lying flat with legs up, would raise blood pressure even more.
NCLEX tip: sit up, loosen anything tight, then find and remove the trigger, starting with the bladder.
How did you do? Tell us below.
Did you get it right? What other spinal cord injury priorities do you always remember?
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