A patient was diagnosed with Bell's palsy. Which intervention should the nurse include in the care of this patient?

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.

A: "Cluster." Cluster headaches are characterized by severe, unilateral pain, often described as sharp or burning rather than throbbing. They typically occur in cyclical patterns or clusters and are often accompanied by autonomic symptoms, such as nasal congestion or tearing, rather than photophobia.
B: "Tension-type." Tension-type headaches are generally bilateral and described as a dull, pressing, or tightening sensation rather than throbbing. They are not usually associated with photophobia or a family history of migraines, making this option less likely.
C: "Frontal-type." Frontal-type headaches can occur in the forehead area but do not have a specific classification as a primary headache type. They may be associated with sinus issues or tension but do not fit the description of unilateral, throbbing pain with photophobia or family history.
D: "Migraine." Migraines are typically unilateral and throbbing, often preceded by premonitory symptoms such as photophobia or aura. The association with family history suggests a genetic predisposition to migraines, further supporting this diagnosis.