A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

A. The client's blood pressure becomes elevated: Hypertension is a hallmark sign of autonomic dysreflexia, but it is a result of the dysreflexic episode, not a risk factor. Identifying elevated blood pressure helps recognize that the client is currently experiencing the condition, rather than predicting its onset. B. The client states having a severe headache: Severe headache is a common symptom during an episode of autonomic dysreflexia due to sudden hypertension. Like elevated blood pressure, it indicates that the condition is occurring rather than signaling risk before it happens. C. The client's bladder becomes distended: Bladder distention is the most common precipitating factor for autonomic dysreflexia in clients with spinal cord injuries at T6 or above. The distention stimulates sympathetic reflexes below the level of injury, which can trigger a hypertensive crisis if not promptly relieved, making it a key risk indicator. D. The client states having nasal congestion: Nasal congestion may occur during an episode of autonomic dysreflexia as a parasympathetic response, but it is not a risk factor. It reflects the body’s reaction once dysreflexia has been initiated rather than a predictive factor.