A patient with a T1 level spinal cord injury reports severe headache and an anxious feeling. What is the most appropriate initial nursing action?

• A. Calm the patient and create a soothing environment
• B. Assess for a full bladder
• C. Notify the healthcare provider
• D. Prepare the patient for diagnostic radiography

Answer: (B)

Autonomic dysreflexia is a life-threatening response that can occur in people with spinal cord injuries above the mid-thoracic level. It happens when a noxious stimulus below the level of injury triggers an excessive sympathetic reaction, leading to a sudden rise in blood pressure. The warning signs often include a severe headache and anxiety, as the body reacts to the unexpected hypertension.

The most important first action is to identify and relieve the triggering stimulus, with bladder distension being the most common cause in hospitalized patients. Assessing for a full bladder and ensuring it’s drained promptly can stop the reflex and bring the blood pressure back toward normal. If the bladder is distended, catheterize or drain the bladder and recheck the patient’s vitals. After the trigger is relieved, place the patient in an upright position to help lower blood pressure, continue to monitor blood pressure closely, and notify the healthcare provider if symptoms persist or blood pressure remains elevated despite relief of the trigger.

Calming the patient and creating a soothing environment is helpful for comfort, but it does not address the underlying dangerous process. Preparing for radiography or immediately notifying the provider without first addressing the trigger would delay essential treatment.