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A nurse is caring for a client who has a spinal cord infury and has developed autonomic dysreflexia. Identify the sequence of step the nurse should take. ( move the steps into the box on the right, placing then in the order of performance. Use all the steps.)



Indicate the risk for autonomic dysreflexia in the client’s medical record

Administer an antihypertensive medication intravenously

Place the client in an uprights sitting position.

Comfirm that the client’s bladder is empty

Verified Answer :

tianmartinez3510

Autonomic dysreflexia is a serious condition that requires prompt and effective intervention. The following sequence of steps should be taken by the nurse in the correct order:

1. Place the client in an upright sitting position.
- This helps to lower blood pressure by utilizing gravity.

2. Confirm that the client’s bladder is empty.
- A distended bladder is a common trigger for autonomic dysreflexia. If the bladder is full, catheterization may be necessary.

3. Administer an antihypertensive medication intravenously.
- This will help manage and reduce the dangerously high blood pressure associated with autonomic dysreflexia.

4. Indicate the risk for autonomic dysreflexia in the client’s medical record.
- Documentation ensures that all healthcare providers are aware of the client's condition and the potential for recurrence, allowing for better prevention and management in the future.

So, the steps in order are:

1. Place the client in an upright sitting position.
2. Confirm that the client’s bladder is empty.
3. Administer an antihypertensive medication intravenously.
4. Indicate the risk for autonomic dysreflexia in the client’s medical record.

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