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?

Choice A rationale Assessing the client for bladder distention is the priority action. Autonomic dysreflexia is a medical emergency in individuals with spinal cord injury above T6, triggered by noxious stimuli below the level of injury. A common cause is bladder distention, which acts as a strong afferent stimulus. Emptying the bladder can often alleviate the hypertensive crisis by removing the initiating stimulus, thus preventing further complications like stroke or seizure. Choice B rationale Placing the client in a high-Fowler's position is an important intervention to help manage the severe hypertension associated with autonomic dysreflexia. Gravity can aid in venous pooling in the lower extremities, thereby reducing venous return to the heart and consequently lowering blood pressure. However, identifying and removing the trigger (like bladder distention) takes precedence over positional changes. Choice C rationale Administering a nitrate antihypertensive, such as nifedipine or hydralazine, may be necessary if conservative measures (identifying and removing the trigger, positioning) do not resolve the severe hypertension. However, pharmacological intervention is a secondary step. The immediate priority is to identify and remove the underlying cause of the autonomic dysreflexia before administering medication, as addressing the cause can often resolve the crisis without drugs. Choice D rationale Obtaining the client's heart rate is part of a complete vital sign assessment during autonomic dysreflexia. While blood pressure is markedly elevated, bradycardia (slow heart rate) often accompanies the hypertension due to vagal stimulation above the level of the spinal cord injury. Monitoring heart rate is crucial for a comprehensive understanding of the client's physiological response but does not take precedence over identifying the precipitating stimulus. .