A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?

A. "My nose gets blocked during the headache." Nasal congestion is a common symptom of cluster headaches, which are associated with autonomic symptoms such as tearing, rhinorrhea, and eyelid drooping. This is not characteristic of tension-type headaches.
B. "I feel some pressure on my neck during the headache." Tension-type headaches are often described as a "band-like" pressure or tightness around the head, with muscle tension in the neck and shoulders. The pain is typically bilateral, mild to moderate, and not aggravated by routine activities. Neck muscle stiffness or tenderness is a common feature.
C. "My eyes hurt during the headache." Eye pain is more commonly associated with migraine or cluster headaches. Cluster headaches often present with sharp, stabbing pain behind one eye, while migraines can cause ocular pain with light sensitivity.
D. "I can see bright lights before the onset of the headache." Seeing bright lights or an aura is a hallmark symptom of migraine headaches with aura, not tension-type headaches. Tension headaches do not typically have neurological symptoms like visual disturbances.

A. Examine the client for areas of skin breakdown. Skin breakdown can be a trigger for autonomic dysreflexia (AD) due to noxious stimuli, but assessing the skin is not the priority action. The immediate concern is to lower the client's blood pressure to prevent complications such as stroke or seizures.
B. Place the client in a sitting position. The first priority in autonomic dysreflexia is to place the client in a sitting position (or at least 45 degrees). This promotes blood pooling in the lower extremities and helps reduce dangerously high blood pressure. AD is a medical emergency in clients with spinal cord injuries at T6 or above, requiring immediate intervention.
C. Check the client for a fecal impaction. A fecal impaction is a common cause of AD, but the priority is to first lower the blood pressure before assessing for the trigger. Once the client is positioned appropriately, the nurse can assess for bowel or bladder distention as a potential cause.
D. Check the client’s bladder for distention. A distended bladder is the most common cause of AD, but assessment should be done after positioning the client upright. If urinary retention is identified as the trigger, the nurse should immediately catheterize the client to relieve the obstruction.