A nurse is caring for a toddler who has varicella zoster. Which of the following actions should the nurse take?

A. Decrease in blood pressure: Autonomic dysreflexia is characterized by a sudden increase in blood pressure, not a decrease. Hypotension is more typical of spinal shock, making low blood pressure inconsistent with autonomic dysreflexia.

B. Increase in heart rate: During autonomic dysreflexia, the body often responds with bradycardia rather than tachycardia due to baroreceptor-mediated parasympathetic activation. An elevated heart rate is not a typical sign of this condition.

C. Client report of eye twitching: Eye twitching is not associated with autonomic dysreflexia. This symptom may indicate a neurological or electrolyte issue, but it does not help identify the acute hypertensive crisis characteristic of autonomic dysreflexia.

D. Client report of sudden headache: A sudden, severe headache is a hallmark symptom of autonomic dysreflexia caused by abrupt hypertension. This finding, along with other signs such as flushed skin, nasal congestion, and sweating above the level of injury, indicates the need for immediate intervention to prevent complications such as stroke.

A. Report to the nurse manager: Reporting suspected chemical impairment to the nurse manager is the appropriate action because it ensures the concern is addressed through proper channels and in accordance with facility policy. This protects client safety, supports the impaired nurse, and allows for formal investigation and intervention.

B. Set up a time to meet with the nurse: Confronting the nurse directly may be unsafe, delay necessary intervention, and place clients at risk. Addressing the issue through the manager ensures immediate attention while maintaining professional and legal standards.

C. Assume care of the nurse's assigned clients: While client safety is critical, simply taking over assignments does not address the underlying concern or ensure the impaired nurse receives evaluation and support. Reporting is still required.

D. Ask another staff nurse to confirm the suspicion: Seeking confirmation from peers can lead to gossip or breaches of confidentiality and does not follow established protocols. Concerns should be reported through formal channels to protect clients and staff.