一位 T4 脊髓損傷病人突然主訴劇烈搏動性頭痛，護理師發現其損傷部位以上大量出汗，血壓為 190/110 mmHg。護理師的第一個動作應為何？
A client with a T4 spinal cord injury reports a sudden, severe pounding headache and is found to be profuse sweating above the level of injury. The blood pressure is 190/110 mmHg. What should be the nurse's first action?
- AAssess the client for fecal impaction via digital rectal exam透過數位直腸檢查評估病人是否有糞便嵌塞
- BPlace the client in a sitting position or elevate the head of bed to 45-90 degrees✓ 正解將病人置於坐姿或將床頭抬高 45-90 度
- CCheck the client's urinary catheter for kinks or obstruction檢查病人的導尿管是否有扭曲或阻塞
- DAdminister prescribed hydralazine intravenously靜脈注射處方藥物 Hydralazine
此臨床表現為典型的自主神經反射異常（Autonomic Dysreflexia, AD），這是一種發生於 T6 或以上脊髓損傷病人的急症。由於損傷平面以下的有害刺激（如膀胱過度充盈、糞便嵌塞）引起交感神經過度反應，導致嚴重的血管收縮與高血壓。護理優先原則是：1. 立即利用姿勢性低血壓效應（Sit the patient up）來降低血壓，這是首要保護腦血管的動作。2. 尋找並移除誘因。雖然檢查尿管（C）和評估糞便（A）是尋找誘因的重要步驟，但必須在擺位之後進行。給予降壓藥（D）通常是在姿勢調整及移除誘因後血壓仍持續高企時才執行。若不立即處理，可能導致腦出血或癲癇，因此『立即坐起』是救命的第一步。
This clinical presentation is classic for autonomic dysreflexia (AD), an emergency that occurs in clients with spinal cord injury at T6 or above. Noxious stimulation below the level of injury (such as bladder distension or fecal impaction) triggers an exaggerated sympathetic response, producing severe vasoconstriction and hypertension. The nursing priorities are: 1. Immediately use the effect of orthostatic hypotension by sitting the client up to lower the blood pressure — this is the first action to protect the cerebral vasculature. 2. Identify and remove the triggering stimulus. Although checking the catheter (C) and assessing for fecal impaction (A) are important steps in finding the trigger, they must come after positioning. Antihypertensive medication (D) is usually administered only after positioning and removal of the trigger, if the blood pressure remains elevated. If not addressed immediately, AD can lead to intracerebral hemorrhage or seizure; therefore, 'sit the client up immediately' is the life-saving first step.
美國 NCLEX 非常強調 Autonomic Dysreflexia 的護理程序：Position -> Assessment (Bladder/Bowel) -> Intervention (Remove stimulus) -> Meds。台灣臨床教育同樣重視此急症，但在實務上，護理師常會與醫師同時到場，藥物給予的速度可能與擺位同步，但在考試中必須選擺位。