病人被診斷為自主神經反射失調（Autonomic dysreflexia）。護理師的第一步行動為何？
A client is diagnosed with autonomic dysreflexia. What is the nurse's immediate action?
- APlace the client in a high-Fowler's position✓ 正解將病人置於高福勒氏體位
- BAdminister antihypertensive medication給予抗高血壓藥物
- CNotify the physician通知醫師
- DCheck the urinary catheter for kinks檢查導尿管是否有扭結
自主神經反射失調（Autonomic Dysreflexia）是脊髓損傷（通常在 T6 以上）的緊急併發症，最常見誘因為膀胱過脹、腸道阻塞或皮膚刺激。其臨床表現為突發性高血壓、心跳過緩與頭痛。護理師應立即採取的行動是降低血壓並移除刺激源。坐起是為了利用重力誘導姿勢性低血壓，快速緩解高血壓帶來的腦出血風險。
Autonomic dysreflexia is an emergent complication of spinal cord injury (typically above T6) and is most commonly triggered by bladder distention, bowel obstruction, or skin stimulation. Clinical manifestations include sudden severe hypertension, bradycardia, and headache. The nurse's immediate action is to lower the blood pressure and remove the noxious stimulus. Placing the client in a sitting position uses gravity to induce postural hypotension, rapidly relieving the risk of cerebral hemorrhage caused by the hypertensive crisis.