ESTUDYR
NCLEX-RN CASE STUDY: AUTONOMIC DYSREFLEXIA
Client Scenario
1400 Nurses' Notes:
A 26-year-old male with a history of a T4 spinal cord injury (SCI) is admitted for
rehabilitation. He suddenly rings his call bell and reports a "pounding headache" and feeling
extremely flushed. He appears anxious and is sweating profusely.
Physical Assessment:
Neurological: Alert; reports blurred vision and nasal congestion.
Integumentary: Significant redness (flushing) and diaphoresis noted above the T4
level. Skin below the T4 level is pale, cool, and has "goosebumps" (piloerection).
Vital Signs: BP 210/108, HR 52, RR 20. (Baseline BP: 110/60).
Item 1: Recognizing Cues (Visual/Diagram)
Question: The nurse observes the client's symptoms. Which diagram correctly illustrates the
physiological presentation of Autonomic Dysreflexia?
Correct Findings to Identify:
✅Pounding Headache
✅Severe Hypertension (BP > 200/100)
✅Bradycardia (Slow heart rate)
✅Flushing/Sweating above the level of injury
✅Pale/Cool skin below the level of injury
Rationale: Autonomic Dysreflexia is an uninhibited sympathetic response to a noxious
stimulus (like a full bladder). The body reacts with massive vasoconstriction below the injury
(causing high BP). The brain tries to compensate by slowing the heart (Bradycardia) and
dilating vessels above the injury (Flushing).
Item 2: Analyzing Cues (Pathophysiology)
NCLEX-RN CASE STUDY: AUTONOMIC DYSREFLEXIA
Client Scenario
1400 Nurses' Notes:
A 26-year-old male with a history of a T4 spinal cord injury (SCI) is admitted for
rehabilitation. He suddenly rings his call bell and reports a "pounding headache" and feeling
extremely flushed. He appears anxious and is sweating profusely.
Physical Assessment:
Neurological: Alert; reports blurred vision and nasal congestion.
Integumentary: Significant redness (flushing) and diaphoresis noted above the T4
level. Skin below the T4 level is pale, cool, and has "goosebumps" (piloerection).
Vital Signs: BP 210/108, HR 52, RR 20. (Baseline BP: 110/60).
Item 1: Recognizing Cues (Visual/Diagram)
Question: The nurse observes the client's symptoms. Which diagram correctly illustrates the
physiological presentation of Autonomic Dysreflexia?
Correct Findings to Identify:
✅Pounding Headache
✅Severe Hypertension (BP > 200/100)
✅Bradycardia (Slow heart rate)
✅Flushing/Sweating above the level of injury
✅Pale/Cool skin below the level of injury
Rationale: Autonomic Dysreflexia is an uninhibited sympathetic response to a noxious
stimulus (like a full bladder). The body reacts with massive vasoconstriction below the injury
(causing high BP). The brain tries to compensate by slowing the heart (Bradycardia) and
dilating vessels above the injury (Flushing).
Item 2: Analyzing Cues (Pathophysiology)
