During a bladder training program for a client with spinal cord injury using intermittent catheterization, the client suddenly complains of a throbbing headache. Noting that the client's blood pressure is elevated, the priority action by the nurse is to
A) catheterize the client.
B) limit fluids for the remainder of the day.
C) notify the physician immediately.
D) place the client flat in bed.

Question

Quizplus · Accepted Answer

Autonomic dysreflexia is a potentially life-threatening complication that can affect spinal cord-injured clients. The most frequent cause is bladder distention or feces in the rectum. Nursing interventions involve removing the triggering stimuli by reestablishing urine flow or by removing fecal impaction, if necessary. The nurse would catheterize the client, monitor the client's vital signs every 5 minutes, raise the head of the bed to a semi-Fowler position, and notify the physician. Catheterizing the client takes priority over notifying the physician because it addresses the manifestations directly and may remove the irritating stimulus, potentially preventing serious complications.

During a Bladder Training Program for a Client with Spinal