The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders: Select all that apply.

Choice A reason: Initiating a bowel regimen program is essential to avoid constipation, which can be a trigger for autonomic dysreflexia in patients with spinal cord injuries. Ensuring regular bowel movements helps prevent the discomfort and complications that can lead to this potentially life-threatening condition.Choice B reason: Applying tight-fitting clothing is contraindicated as it can cause skin irritation, pressure sores, and other discomforts that could trigger autonomic dysreflexia. Loose and comfortable clothing is recommended to prevent these issues.Choice C reason: Completing frequent skin checks is crucial for detecting and preventing pressure ulcers, skin infections, and other skin conditions that can act as noxious stimuli, triggering autonomic dysreflexia. Regular skin assessments help ensure early identification and management of potential issues.Choice D reason: Restricting all patient visitors is not necessary for preventing autonomic dysreflexia. While it is important to manage the patient's environment and stress levels, complete visitor restriction is not a standard intervention for this condition.Choice E reason: Inserting an indwelling Foley catheter is beneficial for managing bladder function and preventing urinary retention, a common trigger for autonomic dysreflexia. Continuous bladder drainage helps prevent distention and the subsequent risk of triggering this condition.