Complete the following sentence by using the lists of options.

The nurse anticipates the client will likely require

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as evidenced by the client's 

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A. Lying down in a quiet room may not be the best approach as it may isolate the client further. A more active approach is needed to engage with the client.
B. Asking the client directly what they are hearing helps assess the content of the hallucinations and can
provide insight into the client’s experience.
C. Avoiding eye contact may increase anxiety or suggest a lack of concern. Maintaining appropriate eye contact is generally supportive.
D. Referring to hallucinations as real can reinforce delusions and is not therapeutic.

1. Perform suctioning

Contraindicated

Suctioning can be a stressor to the body, and in patients with autonomic dysreflexia, it could potentially exacerbate the condition and lead to further increases in blood pressure. In autonomic dysreflexia, managing the underlying trigger (such as a full bladder or bowel impaction) is key, not suctioning unless there is a specific need related to respiratory issues. This action could make the elevated blood pressure worse.
2. Withhold pain medication for headache until other manifestations resolve

Contraindicated
Pain management is critical in a patient with autonomic dysreflexia. The headache is a significant symptom of autonomic dysreflexia and needs to be addressed immediately, as pain is often the trigger. Withholding pain medication could worsen the client's symptoms and contribute to further complications. Proper management of pain should occur concurrently with interventions to address the elevated blood pressure.
3. Assess blood pressure every 15 minutes

Anticipated
Monitoring blood pressure is crucial in patients with autonomic dysreflexia to track changes and assess for improvement or worsening of hypertension. The nurse should frequently assess the client’s blood pressure to ensure it is returning to normal after appropriate interventions are initiated. Autonomic dysreflexia requires continuous monitoring of blood pressure to avoid complications such as stroke or cardiac events.
4. Administer nifedipine

Contraindicated
While nifedipine (a calcium channel blocker) is used to manage hypertension, it is not typically recommended as a first-line treatment for autonomic dysreflexia in spinal cord injury patients. Instead, interventions should focus on removing the triggering stimulus (e.g., bladder distension, constipation, or pressure ulcers). If blood pressure does not respond, other medications such as nitroglycerin or hydralazine may be used, but nifedipine is not the preferred option.
5. Assess for urinary retention

Anticipated
Urinary retention is a common trigger for autonomic dysreflexia in patients with spinal cord injuries, particularly those with injuries at or above T6. If the client is experiencing symptoms of autonomic dysreflexia, one of the first steps is to assess for urinary retention. If the bladder is full, catheterization may be required to relieve the pressure and help normalize the blood pressure. The nurse should assess the client’s urinary status promptly.
6. Place client in supine position

Contraindicated
In the case of autonomic dysreflexia, placing the client in a supine position could potentially worsen the elevated blood pressure by increasing venous return and making it harder for the body to normalize blood pressure. The client should be positioned sitting upright or at a 45-degree angle, which can help lower blood pressure by promoting venous pooling and reducing the effects of the autonomic dysreflexia response.