— 生理適應 · HARD · MCQ —
一位 T4 脊髓損傷病人，突發劇烈頭痛與心跳過慢。護理師首要行動為何？
A nurse is caring for a client with a spinal cord injury at the T4 level. The client develops sudden severe headache and bradycardia. What is the priority nursing action?
- ACheck for urinary retention or bladder distention✓ 正解檢查是否有尿液滯留或膀胱脹滿
- BPerform a neurological assessment進行神經學評估
- CAdminister an analgesic for the headache給予止痛藥以緩解頭痛
- DCall the physician for a blood pressure medication order聯絡醫師開立血壓藥物處方
— Explanation · 中文詳解 —
病人出現自主神經反射異常（Autonomic Dysreflexia），這是 T6 以上脊髓損傷的緊急併發症。最常見原因是膀胱脹滿。首要行動是處理誘發因子，即檢查並引流尿液，以降低交感神經刺激，改善高血壓與心跳過慢。
The client is exhibiting autonomic dysreflexia, an emergency complication of spinal cord injury at T6 or above. The most common trigger is bladder distention. The first action is to address the precipitating factor by checking for and draining urinary retention to reduce sympathetic stimulation, which corrects the hypertension and bradycardia.
✦ 台美臨床差異
兩地皆高度重視脊髓損傷的反射異常識別，屬於護理專業中的高階緊急處置知識。