A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

Choice A rationale Checking the client for fecal impaction is a necessary intervention because a full rectum can be a powerful noxious stimulus that triggers autonomic dysreflexia in clients with spinal cord injuries above T6. However, this is a secondary action. The nurse must first address the life-threatening hypertension associated with this condition by changing the client's position to utilize orthostatic changes to lower the blood pressure before performing an invasive rectal exam. Choice B rationale Examining the client for areas of skin breakdown or restrictive clothing is an important part of identifying the triggering cause of autonomic dysreflexia. Pressure ulcers or even a small wrinkle in the bedsheets can stimulate the sympathetic nervous system. While this is part of the troubleshooting process, it is not the first action. Immediate physiological stabilization through positioning must occur before the nurse begins a head-to-toe search for the source of irritation. Choice C rationale The first action the nurse should take is to place the client in a sitting position or elevate the head of the bed to 90 degrees. Autonomic dysreflexia causes extreme, rapid hypertension. Sitting the client up utilizes gravity to cause blood to pool in the lower extremities, which helps lower the blood pressure naturally through orthostatic effect. This immediate non-pharmacological intervention is the priority to prevent cerebral hemorrhage or seizures during a hypertensive crisis. Choice D rationale Bladder distention is the most common cause of autonomic dysreflexia, and checking the urinary drainage system or performing a bladder scan is a vital part of the treatment protocol. However, even though bladder issues are frequently the culprit, the very first nursing action must be to lower the dangerously high blood pressure by sitting the client up. Once the client is positioned safely, the nurse should then immediately assess the bladder and catheter.