— 降低風險 · HARD · SATA —
護理師照護一位脊髓損傷病人，哪些臨床發現應與自主神經反射亢進（AD）有關？（選所有適合的）
A nurse is caring for a client with a spinal cord injury. Which findings should the nurse associate with autonomic dysreflexia? (Select all that apply.)
- ASevere, throbbing headache✓ 正解劇烈、搏動性頭痛
- BBradycardia✓ 正解心動過緩
- CHypotension低血壓
- DFlushed skin above the level of injury✓ 正解損傷平面以上皮膚潮紅
- ESevere sweating above the level of injury✓ 正解損傷平面以上大量出汗
— Explanation · 中文詳解 —
自主神經反射亢進（AD）是危急狀況。典型症狀包含高血壓、嚴重頭痛、受傷平面以上的潮紅與多汗。由於迷走神經代償，心跳常呈現過慢（Bradycardia）。C 為錯誤，AD 伴隨的是劇烈高血壓，而非低血壓。
Autonomic dysreflexia (AD) is a medical emergency. Typical symptoms include hypertension, severe headache, and flushing and diaphoresis above the level of injury. Because of compensatory vagal stimulation, the heart rate is often slow (bradycardia). Option C is incorrect; AD is accompanied by severe hypertension rather than hypotension.
✦ 台美臨床差異
美台護理師皆接受 AD 的緊急處理訓練，強調「先移除誘因（如導尿管阻塞）」而非僅是給降壓藥。