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Autonomic dysreflexia question

NCLEX   (21,923 Views | 22 Replies)

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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?

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89 Posts; 3,383 Profile Views

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

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11 Posts; 650 Profile Views

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

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221 Posts; 4,167 Profile Views

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.

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Double-Helix has 9 years experience as a BSN, RN and specializes in PICU, Sedation/Radiology, PACU.

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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.

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1 Follower; 310 Posts; 8,005 Profile Views

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.

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131 Posts; 5,074 Profile Views

definitely check cath first!

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373 Posts; 11,898 Profile Views

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

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106 Posts; 3,126 Profile Views

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.

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jjrodriguez is a BSN, RN and specializes in ICU, ED, cardiac, surgery, cath lab..

46 Posts; 3,708 Profile Views

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.

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Esme12 has 40 years experience as a ASN, BSN, RN and specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

6 Followers; 4 Articles; 20,908 Posts; 149,571 Profile Views

[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.

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