In a spinal cord injury patient experiencing autonomic dysreflexia with severe headache and hypertension, what is the first action the nurse should take?

• A. Notify the provider
• B. Sit the client upright in bed
• C. Check the client's urinary catheter for blockage
• D. Administer antihypertensive medication

Answer: (C)

Autonomic dysreflexia is a life-threatening reaction after a spinal cord injury, where a noxious stimulus below the injury (most often bladder distension) triggers an exaggerated sympathetic response that raises blood pressure. The immediate priority is to identify and remove the triggering stimulus. The bladder is the most common trigger, and a blocked catheter is a frequent cause of bladder distension. By checking the urinary catheter for blockage and draining the bladder, you address the root cause of the crisis, which can rapidly reduce the hypertension and alleviate the severe headache.

If the blockage is found and cleared and the BP begins to fall, you can proceed with additional supportive steps like elevating the head of the bed to help further lower blood pressure and continuing to monitor. If the pressure remains high after addressing the bladder, then notifying the provider and considering other interventions or medications would be appropriate.