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Autonomic dysreflexia question

in kaplan question trainer 7, there is a question about this.

patient has pounding headache and profuse sweating, what should the nurse do first

options: elevate HOB

options: check catheter

i chose elevate hob but the answer is check catheter

but a book and study guide said to elevate but kaplan said to check catheter

which is right for nclex?

My answer for that is check the catheter it's bec. In autonomic dysreflexia the signs and symptoms are high bp,confusion, lethargy and diaporesis. You must first address the cause of the autonomic dysreflexia which is bladder distention. Which is checking catheter is part of assessment which leads you to bladder distention. While HOB is nothing to do with the cause of the AD because it is not an airway probs... Hope it helps... This is in my opinion lets wait for others to comment. Thnks

I agree..an overdistended bladder can cause autonomic dysreflexia..I would check the catheter first

I agree, the question is about the distended bladder. What is your priority to address the issue that causing autonomic dysreflexia. It doesn't say patient is having sob, hunger of air.

Double-Helix specializes in PICU, Sedation/Radiology, PACU.

One of the most common causes of autonomic dysreflexia is bladder distention.

Yes, elevating the HOB is easy and might help with the headache and blood pressure, but this question is assessing your knowledge of autonomic dysreflexia and your ability to recognize which assessments/interventions will correct the underlying issue, not simply the symptoms of the problem.

If you get a question about autonomic dysreflexia on NCLEX, the answer will almost always relate to bladder distention or constipation.

for autonomic dysreflexia always think bladder distention or impacted bowel - so for this answer, you check catheter over elevating HOB if those are your anwers.

If checking the cath is not one of the choice pick elevate head of bed first before taking vs.

in kaplan question trainer 7, there is a question about this.

patient has pounding headache and profuse sweating, what should the nurse do first

options: elevate HOB

options: check catheter

i chose elevate hob but the answer is check catheter

but a book and study guide said to elevate but kaplan said to check catheter

which is right for nclex?

I just had a similar question on the qbanks, and the answer was the reverse...place pt in sitting position. Did the question specify that the patient had an indwelling cath? Or did it just say pt had a SCI and had x symptoms?

Question from my qbank: This patient presents with a pounding HA, diaphoretic, etc...which is suggestive of severe RAPID hypertension...it makes sense to elevate HOB because you want to decrease the blood pressure and ICP immediately...since there is a possibility of cerebral hemorrhage and SEIZURES. After elevating the HOB, immediately empty the bladder.

So my other answer choices besides HOB, were "have the patient empty the bladder", or "Examine the rectum"...in my case, having the patient emptying the bladder and examining the rectum would take longer than elevating HOB...in your case, checking for a kink in catheter is quicker than elevating HOB.

Kaplan tends to be very very tricky with wording...and some of their rationales don't make sense, lol.

jjrodriguez specializes in ICU, ED, cardiac, surgery, cath lab..

That's strange. I knew we always check for the bladder if we suspect autonomic dys, but I remember doing a practice question that had both "elevate HOB" and "check bladder/cath" as answer choices and the answer was "elevate HOB". I think the rationale was to prevent hypertensive stroke and this is the most immediate intervention. Of course, in real life all of these would be done about the same time.

Esme12 specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

[color=#1122cc]autonomic dysreflexia and hyperreflexia ....a great site.

autonomic dysreflexia, also known as hyperreflexia, means an over-activity of the autonomic nervous system causing an abrupt onset of excessively high blood pressure. persons at risk for this problem generally have injury levels above t-5. autonomic dysreflexia can develop suddenly and is potentially life threatening and is considered a medical emergency. if not treated promptly and correctly, it may lead to seizures, stroke, and possobly death.

ad occurs when an irritating stimulus is introduced to the body below the level of spinal cord injury, such as an overfull bladder. the stimulus sends nerve impulses to the spinal cord, where they travel upward until they are blocked by the lesion at the level of injury. since the impulses cannot reach the brain, a reflex is activated that increases activity of the sympathetic portion of autonomic nervous system. this results in spasms and a narrowing of the blood vessels, which causes a rise in the blood pressure.

signs & symptoms

  • pounding headache
    (caused by the elevation in blood pressure)
  • goose pimples
  • sweating above the level of injury
  • nasal congestion
  • slow pulse
  • blotching of the skin
  • restlessness
  • hypertension (blood pressure greater than 200/100)
  • flushed (reddened) face
  • red blotches on the skin above level of spinal injury
  • sweating above level of spinal injury
  • nausea
  • slow pulse (
  • cold, clammy skin below level of spinal injury

the most common cause seems to be overfilling of the bladder. this could be due to a blockage in the urinary drainage device, bladder infection (cystitis), inadequate bladder emptying, bladder spasms, or possibly stones in the bladder.

the second most common cause is a bowel that is full of stool or gas. any stimulus to the rectum, such as digital stimulation, can trigger a reaction, leading to autonomic dysreflexia.

other causes include skin irritations, wounds, pressure sores, burns, broken bones, pregnancy, ingrown toenails, appendicitis, and other medical complications.

in general, noxious stimuli (irritants, things which would ordinarily cause pain) to areas of body below the level of spinal injury. identify and remove the offending stimulus .

[color=#1122cc]autonomic dysreflexia in spinal cord injury medscape.....requires registration but is free if you want to konw more.

Double-Helix specializes in PICU, Sedation/Radiology, PACU.

I just had a similar question on the qbanks, and the answer was the reverse...place pt in sitting position. Did the question specify that the patient had an indwelling cath? Or did it just say pt had a SCI and had x symptoms?

Question from my qbank: This patient presents with a pounding HA, diaphoretic, etc...which is suggestive of severe RAPID hypertension...it makes sense to elevate HOB because you want to decrease the blood pressure and ICP immediately...since there is a possibility of cerebral hemorrhage and SEIZURES. After elevating the HOB, immediately empty the bladder.

So my other answer choices besides HOB, were "have the patient empty the bladder", or "Examine the rectum"...in my case, having the patient emptying the bladder and examining the rectum would take longer than elevating HOB...in your case, checking for a kink in catheter is quicker than elevating HOB.

Kaplan tends to be very very tricky with wording...and some of their rationales don't make sense, lol.

The difference between this question and the OP's is that this one doesn't mention autonomic dysreflexia, nor does it suggest that the patient has a previous neurological injury (such as paralysis) that might make them susceptible to autonomic dysreflexia.

In the OP's question, the wording clearly mentions that you're dealing with an autonomic dysreflexia response. Therefore you would choose the best answer that is most likely to correct the patient's most serious problem. In this case, bladder distention due to a kinked or clamped catheter is the most likely cause. (Yes, you assume the patient has a catheter, since the option is to check the catheter.)

In your question, there is no hint or mention of autonomic dysreflexia. Patients with neurological injuries who are susceptible to autonomic dysreflexia cannot simply empty their bladder on their own. The problem is that their body recognizes bladder distention as noxious stimuli, but cannot interpret that stimuli and the damaged nerves do not allow the patient to eliminate it. If this question were truly an autonomic dysreflexia situation, you could not "have the patient empty the bladder" as they would be unable to voluntarily do so without the assistance of a catheter.

Since you have no reason to suspect a previous neurological injury, or autonomic dysreflexia, based on the information provided in the question, the correct answer would be to choose the best answer that most likely reduces the risk of complications from the patient's presenting symptoms. In this case, it would be raising the HOB to reduce cerebral blood pressure.

The trick is in the wording, and these questions are good examples of what not to do with NCLEX questions: Don't assume information that isn't there. So if the question doesn't mention autonomic dysreflexia, paralysis, or neurological injury, don't assume any of the above is present just because they patient's symptoms would be consistent with that diagnosis.

The difference between this question and the OP's is that this one doesn't mention autonomic dysreflexia, nor does it suggest that the patient has a previous neurological injury (such as paralysis) that might make them susceptible to autonomic dysreflexia.

In the OP's question, the wording clearly mentions that you're dealing with an autonomic dysreflexia response. Therefore you would choose the best answer that is most likely to correct the patient's most serious problem. In this case, bladder distention due to a kinked or clamped catheter is the most likely cause. (Yes, you assume the patient has a catheter, since the option is to check the catheter.)

In your question, there is no hint or mention of autonomic dysreflexia. Patients with neurological injuries who are susceptible to autonomic dysreflexia cannot simply empty their bladder on their own. The problem is that their body recognizes bladder distention as noxious stimuli, but cannot interpret that stimuli and the damaged nerves do not allow the patient to eliminate it. If this question were truly an autonomic dysreflexia situation, you could not "have the patient empty the bladder" as they would be unable to voluntarily do so without the assistance of a catheter.

Since you have no reason to suspect a previous neurological injury, or autonomic dysreflexia, based on the information provided in the question, the correct answer would be to choose the best answer that most likely reduces the risk of complications from the patient's presenting symptoms. In this case, it would be raising the HOB to reduce cerebral blood pressure.

The trick is in the wording, and these questions are good examples of what not to do with NCLEX questions: Don't assume information that isn't there. So if the question doesn't mention autonomic dysreflexia, paralysis, or neurological injury, don't assume any of the above is present just because they patient's symptoms would be consistent with that diagnosis.

Sorry, I didn't post the question word for word..but it does deal with Autonomic dysreflexia..Here is the idea of the question

There is patient who sustained a T5 spinal cord injury weeks ago. The nurse observes that the patient is diaphoretic, nauseated, and complaining of a severe headache. Which of the following actions should the nurse take FIRST?

A) Place the patient in a sitting position

B) Have the patient empty his bladder

C) Examine the rectum

D) Administer Apresoline as ordered

question paraphrased TOS copyright.

Edited by Esme12
TOS copyright

Thanks for all the help everyone!

Maybe I should of also included the whole question and rationales

Here it is and I'll add it to my original post:

The patient is 3 days post spinal cord injury at the level of T-5. The patient complains of a pounding headache, and the nurse notes profuse sweating on the patient’s forehead. Which of the following actions, if taken by the nurse, is BEST?

1. Determine the patency of the Foley catheter.

2. Place ice packs on the neck and head.

3. Elevate the head of the bed.

4. Apply a rigid cervical collar.

.Just kidding, can't edit original post. so its here!

question paraphrased/copyright

Edited by Esme12
added note

ahh carygt3 and my question are total opposites, I'd be totally confused on the test if this came up!!!

so check foley is #1 priority?

I'm thinking...if they have a catheter it's quicker to assess than putting up the bed...so check for kinks first. If option does not give catheter option like mines..and says have pt empty bladder, or straight cath pt to alleviate...etc ...elevate HOB instead because it's quicker.

Maybe my question probably doesn't have a indwelling cath option because it has been 4 weeks since pt sustained injury..and are probably having pt train his bladder or something

Your question has an indwelling cath maybe because patient just sustained injury 3 days ago..

So true, now I get it. :)

depends on the options/answers given heh

THANKS EVERYONE!

the other reason you would not choose "administer apresoline as ordered" is because that is part of a medical plan of care, and the nclex wants to know what you as a nurse would assess and do. yes, nurses give medications that are part of the medical plan of care, we are legally obligated to do that (if they are safe), but nclex wants to know if you know nursing assessment and intervention.

Esme12 specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

ahh carygt3 and my question are total opposites, I'd be totally confused on the test if this came up!!!

so check foley is #1 priority?

In the one question it says to check foley the other is to empty the bladder.....In each scenario Which would be the quickest most efficient means to correct the situation.

Check the foley tube or put the head up? the other senario........ get them out of bed to void or put the head up? Which is most likely to get results the quickest.

One is check the foley and the other is to put the head up....LOOK at the question and your options.

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