A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

Choice A rationale A severe headache is a symptom that a client is experiencing autonomic dysreflexia, not a risk factor. This syndrome is a medical emergency characterized by a strong sympathetic surge below the level of the injury, typically T6 or above. The severe, pounding headache is directly caused by the sudden, rapid, and severe elevation in blood pressure, making it a key warning sign of the crisis, not the underlying cause. Choice B rationale Bladder distension is a common trigger or risk factor for autonomic dysreflexia in clients with spinal cord injury at T6 or above, such as a T4 injury. A full bladder or bowel causes sensory input below the injury level, leading to uninhibited sympathetic discharge which results in severe hypertension, the hallmark of this emergency condition. Choice C rationale Elevated blood pressure, or severe hypertension (systolic pressure often >200 mmHg), is a manifestation of autonomic dysreflexia, not an underlying risk factor for its development. The elevated blood pressure results from the sympathetic vasoconstriction below the lesion, which is triggered by an irritating stimulus like an overfull bladder. Choice D rationale Nasal congestion is a sign of autonomic dysreflexia, resulting from the parasympathetic response above the level of the spinal cord injury. Above the lesion, the parasympathetic nervous system tries to compensate for the sympathetic surge, causing vasodilation and increased secretions, leading to symptoms like a flushed face and nasal stuffiness, not the initiating risk. —.