A patient with a spinal cord injury has warm, dry skin, a severe headache, and a blood pressure of 198/104 mmHg. The pulse is 48 per minute. What should the nurse do first?
Correct answer: A. Sit the patient upright and assess for a triggering stimulus
- A. Sit the patient upright and assess for a triggering stimulus
- B. Place the patient flat and encourage oral fluids
- C. Give a prescribed sedative and reassess the blood pressure later
- D. Apply a warm blanket and ask the patient to rest quietly
Explanation
This pattern suggests autonomic dysreflexia, which is an emergency after spinal cord injury. Sitting the patient upright helps lower blood pressure while the nurse rapidly searches for triggers such as bladder distension or a blocked catheter. Lying flat can worsen the hypertension.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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