— 生理適應 · HARD · MCQ —
一位病人診斷為自主神經反射異常（autonomic dysreflexia）。護理師應首先執行哪項護理措施？
A client is diagnosed with autonomic dysreflexia. Which nursing action should the nurse perform first?
- ARaise the head of the bed to high-Fowler's position✓ 正解將床頭抬高至半坐臥位（High-Fowler's position）
- BAdminister an antihypertensive medication給予降壓藥物
- CAssess the skin for pressure ulcers評估皮膚是否有壓瘡
- DCheck the client's bladder for distention檢查病人膀胱是否脹滿
— Explanation · 中文詳解 —
自主神經反射異常（Autonomic Dysreflexia）是一種發生於 T6 以上脊髓損傷病人的危險急症，常由滿脹的膀胱、直腸糞塊或皮膚刺激引起。其特徵為陣發性高血壓。護理師應先將病人調整為高坐臥位（High-Fowler's），以利用重力誘導的姿勢性低血壓來降低腦部壓力，接著再迅速尋找並移除刺激源（如導尿）。
Autonomic dysreflexia is a dangerous emergency that occurs in clients with spinal cord injuries above T6 and is often triggered by a distended bladder, fecal impaction, or skin stimulation. Its hallmark is paroxysmal hypertension. The nurse should first place the client in high-Fowler's position to use gravity to induce orthostatic blood pressure reduction and protect cerebral perfusion, then quickly identify and remove the triggering stimulus (such as catheterization).