一位患有 C5 頸椎損傷病史的病人突然主訴嚴重的搏動性頭痛，血壓測量為 210/110 mmHg。護理師應執行哪些處置？（選所有適合的）
A client with a history of cervical spine injury at C5 suddenly reports a severe, throbbing headache and has a blood pressure of 210/110 mmHg. Which interventions should the nurse perform? (Select all that apply.)
- APlace the client in a high-Fowler's position✓ 正解將病人置於高福勒氏臥位
- BCheck the urinary drainage system for kinks✓ 正解檢查尿液引流系統是否有扭曲
- CPerform a vigorous digital rectal exam to check for impaction進行強烈的數位肛門檢查以確認糞便嵌塞
- DLoosen restrictive clothing or abdominal binders✓ 正解鬆開限制性衣物或腹部束帶
- EMonitor blood pressure every 2 to 5 minutes✓ 正解每 2 至 5 分鐘監測血壓
此病人表現出自主神經反射異常（Autonomic Dysreflexia, AD）的典型症狀，這常見於 T6 以上的脊髓損傷。AD 是一種醫療緊急狀況，未及時處理可能導致腦中風或癲癇。核心概念是：找出並移除引發交感神經過度反應的刺激源。首先，將病人坐起（High-Fowler's）利用姿勢性低血壓效應降低顱內壓。接著，必須尋找常見誘因：膀胱脹（導尿管折疊）、糞便嵌塞（直腸刺激）或皮膚壓迫。注意選項 C 錯誤，因為「用力」的直腸檢查本身就是一種刺激，會加劇高血壓，應在塗抹麻醉軟膏後輕柔檢查。持續監測血壓（E）是必要的，直到壓力下降至基線。整個思路依循：降低血壓 → 移除誘因 → 持續監測。
These findings indicate autonomic dysreflexia (AD), a medical emergency in clients with SCI at or above T6. Management priorities: (A) immediately elevate the head of the bed to high-Fowler's to lower BP via orthostasis; (B) check the urinary system for kinks, distention, or blockage (most common trigger); (D) remove tight clothing/abdominal binders that act as noxious stimuli; (E) monitor BP every 2-5 minutes until stable. (C) is incorrect: a vigorous digital rectal exam itself worsens AD; lidocaine jelly must be applied first and the exam performed gently.
在美國，Autonomic Dysreflexia 被視為護理獨立執業範圍內必須立即識別的急症，護理師通常有既定的 Standing Orders（如導尿、移除壓迫物）。台灣臨床上，護理師也會立即處理，但對於是否能「先坐起病人再通知醫師」的順序，有時會受到單位文化影響，NCLEX 則強調「先坐起」是首要安全步驟。