護理師監測一位三週前發生高位脊髓損傷（T4）的患者。患者自訴嚴重頭痛，血壓為 190/100 mmHg。護理師應優先執行哪項動作？
The nurse is monitoring a client who sustained a high-level spinal cord injury (T4) three weeks ago. The client reports a severe headache and has a blood pressure of 190/100 mmHg. Which action should the nurse perform first?
- ACheck the client's bladder for distension or catheter kinks檢查病人膀胱是否有脹滿或導尿管扭結
- BPerform a digital rectal exam to assess for fecal impaction進行數位肛門檢查以評估是否有糞便嵌塞
- CPlace the client in a high-Fowler's position✓ 正解將病人置於高福勒氏臥位（High-Fowler's position）
- DAdminister the prescribed PRN antihypertensive medication給予處方上的按需（PRN）抗高血壓藥物
這題描述的是自主神經反射失調（Autonomic Dysreflexia, AD），這是一種發生於 T6 以上脊髓損傷患者的緊急醫療狀況。當損傷平面以下的刺激（通常是膀胱脹尿或便秘）引起交感神經過度反應，會導致嚴重的血管收縮與血壓飆升。護理介入的首要步驟是物理性的降低血壓，即將病人置於高坐臥位（High-Fowler's position）。這是因為姿勢改變利用重力使血液蓄積在下肢，可立即產生些微降壓效果，防止腦中風或癲癇發作。接下來才是尋找誘因（檢查膀胱、腸道），並在必要時給予藥物。臨床思路上，雖然檢查誘因（A、B）是根治的方法，但「立即降低血壓」是防止併發症的最高優先（Safety first）。此題難度在於區分「首要物理介入」與「後續處置」。
This item describes autonomic dysreflexia (AD), a medical emergency that occurs in patients with spinal cord injuries at T6 or above. When a stimulus below the level of injury (usually bladder distension or constipation) triggers excessive sympathetic response, severe vasoconstriction and a surge in blood pressure result. The first nursing intervention is a physical maneuver to lower blood pressure: placing the client in a high-Fowler's position. Postural change uses gravity to pool blood in the lower extremities, producing an immediate small reduction in blood pressure and helping prevent stroke or seizure. The next steps are to identify the triggering stimulus (check the bladder and bowel) and administer medication if needed. Clinically, although checking for triggers (A and B) is the definitive treatment, immediately lowering blood pressure is the highest priority for preventing complications (safety first). The difficulty of this question lies in distinguishing the "first physical intervention" from subsequent management.
美國護理指引對於 AD 的處置流程非常標準化，強調「先坐起再找原因」。台灣臨床護理師對於高位脊髓損傷患者的血壓變化亦有高度警覺，但在處置時常會同時進行多項動作。NCLEX 強求單一「First action」，考生必須明確記得姿勢改變優於檢查與給藥。