— 生理適應 · HARD · SATA —
病人被診斷為自主神經反射異常，下列哪些為優先護理措施？（選所有適合的）
A client is diagnosed with autonomic dysreflexia. What are the priority interventions? (Select all that apply.)
- AElevate the head of the bed to 90 degrees✓ 正解將床頭抬高至 90 度
- BAssess for bowel or bladder distention✓ 正解評估是否有腸道或膀胱脹滿
- CAdminister antihypertensive medication✓ 正解給予抗高血壓藥物
- DLoosen restrictive clothing✓ 正解鬆開緊身衣物
- EApply cold packs to the forehead在額頭敷冰袋
— Explanation · 中文詳解 —
自主神經反射異常是脊髓損傷後的急症，首要將床頭抬高以降低血壓（姿勢性低血壓效應）。隨後必須找出刺激源（排尿、排便、皮膚壓迫），給予降血壓藥物及鬆開衣物以緩解症狀。冷敷 forehead 對緩解高血壓無效。
Autonomic dysreflexia is an emergency following spinal cord injury. The first action is to raise the head of the bed to lower blood pressure (through orthostatic effect). The nurse must then identify the triggering stimulus (urination, defecation, skin pressure) and administer antihypertensive medication and loosen restrictive clothing to relieve symptoms. Applying a cold compress to the forehead is ineffective for relieving the hypertensive crisis.
✦ 台美臨床差異
此病在脊髓損傷病房極為重要，美台護理人員均需受過標準化急救訓練，流程相似。