A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

D. Vital sign measurements, including blood pressure, heart rate, respiratory rate, and temperature, are essential for assessing the client's hemodynamic stability and overall condition. A rigid abdomen with rebound tenderness suggests a potential surgical emergency, such as bowel perforation, which could lead to sepsis and hemodynamic instability. Therefore, obtaining vital sign measurements promptly will help determine the severity of the client's condition and guide further interventions.
A. Encouraging ambulation would not be appropriate in this situation because it could exacerbate the client's discomfort and potentially worsen any abdominal pain or tenderness. Ambulation is not the priority when a client presents with signs of a possible bowel perforation.
B. Measure capillary glucose level: While monitoring blood glucose levels is important, especially in clients receiving corticosteroid treatment, it is not the priority when the client is presenting with symptoms suggestive of a serious complication such as bowel perforation. Immediate assessment and intervention to address the abdominal rigidity and rebound tenderness are needed before other assessments can be performed.
C. While bloody stools are a common symptom of IBD exacerbation, the presence of a rigid abdomen with rebound tenderness suggests a more urgent issue, such as bowel perforation, that requires immediate attention. Monitoring for bloody stools should occur concurrently with assessing and managing the client's acute abdominal symptoms.

C. Elevating the head of the bed to 90 degrees (semi-Fowler's position) can help improve respiratory mechanics and lung expansion, making breathing easier for the client. This position can also help reduce the risk of aspiration and improve oxygenation in clients with respiratory distress.
A. Identifying and addressing triggers that exacerbate asthma symptoms is crucial for managing asthma effectively. By determining the client's exposure to triggers such as allergens, pollutants, or irritants, the nurse can help prevent future asthma exacerbations and tailor the client's management plan accordingly. However, this is done after the client is stabilized.
B. While teaching proper inhaler technique is an essential aspect of asthma management, the priority in this scenario is addressing the client's immediate respiratory distress. The client is already receiving a steroid nebulizer treatment, which is aimed at providing rapid relief and improving lung function. Teaching proper inhaler technique can be addressed later once the client's respiratory distress is stabilized.
D. While monitoring pulse oximetry is essential for assessing oxygenation and respiratory status, the frequency of monitoring may need to be increased in a client with asthma in respiratory distress. Clients experiencing respiratory distress may have rapid changes in oxygen saturation levels, necessitating more frequent monitoring to ensure timely intervention if oxygenation deteriorates.