— 照護管理 · HARD · MCQ —
護理師照護一位有脊髓損傷且有自主神經反射失調（autonomic dysreflexia）風險的病人，下列哪種刺激最可能引發此反應？
A nurse is caring for a client with a spinal cord injury who is at risk for autonomic dysreflexia. Which stimulus is most likely to trigger this response?
- ABright lights強光
- BExposure to cold temperatures暴露於低溫
- CPain in the lower extremities下肢疼痛
- DA full bladder or bowel✓ 正解膀胱或腸道脹滿
— Explanation · 中文詳解 —
自主神經反射失調（AD）通常發生在 T6 或 T6 以上的脊髓損傷病人，由膀胱或腸道過度充盈等下方刺激引發。這些刺激會傳遞到損傷部位以上的中樞神經系統，引起不受控制的自主神經反應（如高血壓、頭痛、心跳過慢）。
Autonomic dysreflexia (AD) typically occurs in clients with spinal cord injuries at or above T6 and is triggered by noxious stimuli below the level of injury, such as bladder or bowel overdistension. These stimuli are transmitted to the central nervous system above the level of injury and elicit uncontrolled autonomic responses such as hypertension, headache, and bradycardia.
✦ 台美臨床差異
美國的脊髓損傷照護中心（SCI Centers）在 AD 的預防與急救方面有豐富的經驗和標準化流程；台灣的相關照護也遵循國際標準，但病人教育和居家追蹤可能因資源而異。