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?

Choice A reason: Administering a nitrate antihypertensive is not the first action for autonomic dysreflexia. While it may help manage hypertension, the priority is identifying and removing the triggering stimulus, such as bladder distention, which causes the autonomic response. Addressing the cause prevents further escalation of the life-threatening hypertensive crisis. Choice B reason: Obtaining the client’s heart rate provides additional data but is not the priority. Autonomic dysreflexia is characterized by severe hypertension due to a noxious stimulus below the spinal injury level. Checking for triggers like bladder distention is critical first to eliminate the cause and stabilize blood pressure. Choice C reason: Placing the client in a high-Fowler’s position may help manage hypertension by reducing preload, but it is not the first action. Autonomic dysreflexia requires identifying and removing the trigger, such as bladder distention, to prevent ongoing sympathetic overactivity, which drives the hypertensive crisis in spinal cord injury clients. Choice D reason: Checking for bladder distention is the first action, as it is a common trigger of autonomic dysreflexia in quadriplegia. A distended bladder causes a noxious stimulus, triggering an exaggerated sympathetic response, leading to severe hypertension. Relieving the distention (e.g., via catheterization) addresses the root cause, stabilizing the client’s condition.