Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

A) This can be done if initial non-pharmacological interventions do not relieve symptoms, but it is not the first step. B) Monitoring blood pressure is important, but it is secondary to removing the stimulus causing the dysreflexia. C) Incorrect- While education is important for long-term management, the client is currently experiencing symptoms that need immediate attention. The priority is to assess and address the current symptoms. D) The client is likely experiencing autonomic dysreflexia, characterized by a sudden and severe increase in blood pressure, flushing, headache, and other symptoms triggered by a noxious stimulus below the level of injury. The first step in managing autonomic dysreflexia is to identify and eliminate the triggering stimulus. For clients with a Foley catheter, a common cause of autonomic dysreflexia is bladder distention due to a kinked or obstructed catheter. Relieving any kinks or obstructions in the Foley tubing can immediately alleviate the symptoms.