On the third week of hospitalization following a spinal cord injury, the nurse assesses the client and sees their face is bright red, and the client is sweating profusely. Which nursing action is completed first?

A. Place the patient flat in bed is incorrect. While positioning may help in some situations, placing a patient flat does not address the underlying cause of autonomic dysreflexia, which is potentially life-threatening and requires immediate identification of the trigger. B. Obtain a stat electrocardiogram is incorrect. Cardiac monitoring may be necessary if complications arise, but the priority in autonomic dysreflexia is identifying and relieving the triggering stimulus before secondary complications develop. C. Assess if their retention catheter is blocked is correct. The client’s facial flushing, profuse sweating, and other signs (e.g., headache, hypertension) are classic signs of autonomic dysreflexia, a potentially life-threatening complication in patients with spinal cord injuries at or above T6. The most common trigger is a distended bladder, often due to a blocked urinary catheter. Immediate assessment and relief of bladder distension is the first and most critical action to prevent severe hypertension, stroke, or seizures. D. Massage their lower extremities is incorrect. Massaging the legs does not address the cause of autonomic dysreflexia and could worsen symptoms if the lower extremities have a noxious stimulus (e.g., pressure ulcer or injury).