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BSN 266 HESI Study Guide
|Comprehensive Q&A For Certification
Success 2026
A client with AC7 spinal cord injury (SCI) is experiencing autonomic dysreflexia.
The nurse should first assess the client for which participating factor?
A. An acutely distended bladder.
B. Skeletal traction misalignment
C. A severe pounding headache
D. Profuse forehead diaphoresis - correct-answer-A. An acutely distended
bladder.
Rationale:
A distended bladder is the most common precipitating factor for autonomic
dysreflexia in clients with SCI above T6. Prompt assessment and relief of bladder
distension can quickly reduce the hypertensive crisis.
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Autonomic dysreflexia (AD) is a medical emergency that occurs in people with a
spinal cord injury at or above the T6 level. It is caused by an exaggerated,
uncontrolled response of the autonomic nervous system to a painful or irritating
stimulus below the level of the spinal cord injury, leading to severe hypertension.
Common Triggers
The most common causes include:
Distended bladder (most common)
Full bladder
Kinked or blocked urinary catheter
Bowel impaction or constipation
Skin irritation or injury
Pressure injuries
Tight clothing
Wrinkled bed linens
Fractures or other injuries
Surgical procedures
Labor and delivery.
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Signs and Symptoms
Sudden, severe hypertension (hallmark sign)
Bradycardia (slow heart rate)
Severe, pounding headache
Flushed skin and sweating above the level of injury
Pale, cool skin below the level of injury
Nasal congestion
Blurred vision
Anxiety or feeling of doom
Goosebumps (piloerection)
Nursing Interventions (Priority)
Sit the patient upright immediately (High Fowler's position) to lower blood
pressure.
Loosen tight clothing or restrictive devices.
Identify and remove the trigger:
Check the urinary catheter for kinks or blockage.
Empty the bladder if needed.
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Assess for bowel impaction (only after blood pressure is managed and using
appropriate precautions).
Monitor blood pressure every 2-5 minutes.
Notify the healthcare provider.
Administer prescribed antihypertensive medication (e.g., nifedipine or
nitroglycerin) if blood pressure remains dangerously high after the trigger is
addressed.
NGN:
The client is a 65 Yo male admitted to the medical surgical after a total
cholecystectomy. He has passed medical history of HTN, HF, DMT1, cholelithiasis,
and cigarette smoking 1 pack a day for 20 years. The client has been reporting
pain that is "Barely relieved by pain medication." He has not been able to use the
incentive spirometer every hour as prescribed because, "it is too painful to take a
deep breath."
Postoperative day (POD) 2:
BSN 266 HESI Study Guide
|Comprehensive Q&A For Certification
Success 2026
A client with AC7 spinal cord injury (SCI) is experiencing autonomic dysreflexia.
The nurse should first assess the client for which participating factor?
A. An acutely distended bladder.
B. Skeletal traction misalignment
C. A severe pounding headache
D. Profuse forehead diaphoresis - correct-answer-A. An acutely distended
bladder.
Rationale:
A distended bladder is the most common precipitating factor for autonomic
dysreflexia in clients with SCI above T6. Prompt assessment and relief of bladder
distension can quickly reduce the hypertensive crisis.
,2|Page
Autonomic dysreflexia (AD) is a medical emergency that occurs in people with a
spinal cord injury at or above the T6 level. It is caused by an exaggerated,
uncontrolled response of the autonomic nervous system to a painful or irritating
stimulus below the level of the spinal cord injury, leading to severe hypertension.
Common Triggers
The most common causes include:
Distended bladder (most common)
Full bladder
Kinked or blocked urinary catheter
Bowel impaction or constipation
Skin irritation or injury
Pressure injuries
Tight clothing
Wrinkled bed linens
Fractures or other injuries
Surgical procedures
Labor and delivery.
,3|Page
Signs and Symptoms
Sudden, severe hypertension (hallmark sign)
Bradycardia (slow heart rate)
Severe, pounding headache
Flushed skin and sweating above the level of injury
Pale, cool skin below the level of injury
Nasal congestion
Blurred vision
Anxiety or feeling of doom
Goosebumps (piloerection)
Nursing Interventions (Priority)
Sit the patient upright immediately (High Fowler's position) to lower blood
pressure.
Loosen tight clothing or restrictive devices.
Identify and remove the trigger:
Check the urinary catheter for kinks or blockage.
Empty the bladder if needed.
, 4|Page
Assess for bowel impaction (only after blood pressure is managed and using
appropriate precautions).
Monitor blood pressure every 2-5 minutes.
Notify the healthcare provider.
Administer prescribed antihypertensive medication (e.g., nifedipine or
nitroglycerin) if blood pressure remains dangerously high after the trigger is
addressed.
NGN:
The client is a 65 Yo male admitted to the medical surgical after a total
cholecystectomy. He has passed medical history of HTN, HF, DMT1, cholelithiasis,
and cigarette smoking 1 pack a day for 20 years. The client has been reporting
pain that is "Barely relieved by pain medication." He has not been able to use the
incentive spirometer every hour as prescribed because, "it is too painful to take a
deep breath."
Postoperative day (POD) 2:
