A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

A. While assessment of vital signs is important, this is not the priority when autonomic dysreflexia is suspected. B. The first action is to sit the client upright (high-Fowler’s) to lower blood pressure and reduce the risk of stroke. C. Assessing the client for bladder distention is important, but done after positioning. Bladder distention is the most common trigger of autonomic dysreflexia, but safety and immediate blood pressure reduction come first. D. Medications may be needed if nonpharmacologic interventions fail, but the initial nursing action is positioning and addressing the cause.