A nurse is caring for a client with a C4 spinal cord injury with an indwelling urinary catheter who exhibits signs of autonomic dysreflexia, including a severe headache and hypertension. What should the nurse do first?

Autonomic dysreflexia is a life-threatening condition that occurs in clients with spinal cord injuries at or above T6 due to an exaggerated autonomic response to a noxious stimulus below the level of injury. It is commonly triggered by bladder distention, bowel impaction, or other irritants. This leads to sudden hypertension, pounding headache, bradycardia, and diaphoresis above the level of injury. Immediate identification and removal of the triggering stimulus is the priority to prevent complications such as stroke or seizures. Rationale: A. Administering an antihypertensive medication is not the first action because the priority is to identify and eliminate the underlying cause of the autonomic dysreflexia. While medications may be needed if symptoms persist, treating the trigger (often bladder or bowel-related) is the most immediate and effective intervention. Giving medication without removing the stimulus does not resolve the root cause of the crisis. B. Placing the client in a supine position is incorrect because it can worsen hypertension by increasing venous return and intracranial pressure. The recommended position is to elevate the head of the bed to reduce blood pressure and promote orthostatic pooling of blood in the lower extremities. Positioning alone, however, is not sufficient without addressing the triggering stimulus. C. Checking the urinary catheter for kinks is the priority action because bladder distention is the most common cause of autonomic dysreflexia. An obstructed catheter can lead to rapid bladder filling, triggering the autonomic response. Immediate assessment and relief of urinary retention help reduce blood pressure and resolve symptoms quickly. D. Performing digital rectal stimulation is contraindicated as an initial intervention because it may worsen the episode if a bowel impaction is present and has not been properly prepared for disimpaction. Additionally, rectal stimulation can further increase autonomic stimulation and elevate blood pressure. It should only be done after stabilizing the client and addressing more urgent causes such as bladder obstruction.