病人出現自律神經反射異常（Autonomic Dysreflexia）症狀，護理師應採取哪些措施？（選所有適合的）
A client is experiencing symptoms of autonomic dysreflexia. Which nursing actions are appropriate? (Select all that apply.)
- AElevate the head of the bed to a sitting position✓ 正解將床頭抬高至坐姿
- BCheck the bladder for distention✓ 正解檢查膀胱是否脹滿
- CAdminister an antihypertensive medication as ordered✓ 正解依醫囑給予抗高血壓藥物
- DLoosen tight clothing or binders✓ 正解鬆開緊身衣物或束帶
- EApply a heating pad to the lower extremities在下肢應用熱敷墊
自律神經反射異常（Autonomic Dysreflexia, AD）是脊髓損傷於 T6 以上之病人的醫療急症。其核心病理機制為傷害部位以下的刺激（最常見為膀胱脹滿）引發交感神經劇烈反射，導致嚴重高血壓。護理原則為「立即坐起」以透過重力降低顱內壓，隨後依序排除誘因：檢查導尿管是否阻塞、確認腸道是否受刺激、移除緊身衣物。若血壓持續高於收縮壓 150 mmHg，需依醫囑給予降壓藥，以防中風或心肌梗塞。
Autonomic Dysreflexia (AD) is a medical emergency in clients with spinal cord injury at or above the T6 level. Its core pathophysiologic mechanism involves stimulation below the level of injury (most commonly bladder distention) triggering an exaggerated sympathetic reflex, leading to severe hypertension. Nursing principles include 'immediately sit the client upright' to use gravity to lower intracranial pressure, followed by sequential elimination of triggers: check for urinary catheter obstruction, confirm bowel stimulation, and remove tight clothing. If blood pressure remains greater than 150 mmHg systolic, an antihypertensive should be administered as ordered to prevent stroke or myocardial infarction.
美國臨床對於 AD 的處理非常強調「立即性」，護理師在發現症狀（劇烈頭痛、高血壓、出汗）時，無需等待醫師評估即可執行坐起與檢查尿管之護理措施，這屬於護理師的自主權限（Standing orders）。