A client who was admitted 3 days ago for a bowel obstruction has a liter of lactated Ringer's with potassium chloride (KCI) 20 mEq infusing. The client has been receiving selegiline for depression. When the client reports experiencing a severe headache, the nurse obtains a blood pressure of 200/110 mm Hg. Which action(s) should the nurse take? Select all that apply.

A. Monitor blood pressure and pulse every 15 minutes: A blood pressure of 200/110 mm Hg with a severe headache suggests a hypertensive crisis, which requires close hemodynamic monitoring. Frequent assessment allows early detection of worsening hypertension, arrhythmias, or signs of end-organ damage such as neurologic changes. B. Withhold the next dose of selegiline: Selegiline is a monoamine oxidase inhibitor (MAOI) that increases levels of catecholamines by inhibiting their breakdown. Hypertensive crisis can occur due to excessive sympathetic stimulation, particularly if dietary tyramine or interacting medications are involved. Holding the medication prevents further accumulation. C. Notify healthcare provider of client's findings: Severe hypertension accompanied by headache indicates possible hypertensive emergency requiring immediate medical management. Rapid intervention may include administration of short-acting antihypertensive agents and evaluation for neurologic or cardiac complications. Prompt communication ensures timely treatment. D. Measure hourly urinary output: Measuring hourly urine output provides a real-time assessment of renal perfusion and function, as oliguria can be an early indicator of hypertensive nephropathy or systemic "shock" to the microvasculature. Additionally, since the client is receiving IV fluids maintaining an accurate fluid balance is necessary to prevent fluid overload E. Discontinue the IV infusion: Lactated Ringer’s with potassium chloride does not directly precipitate hypertensive crisis and is not known to interact with selegiline in a way that causes acute severe hypertension. Abrupt discontinuation of IV fluids without provider direction may compromise hydration status, especially in a client with bowel obstruction.