— 生理適應 · HARD · MCQ —
一位病人發生急性自主神經反射異常（Autonomic Dysreflexia），護理師應採取哪項行動？
Which nursing intervention is appropriate for a client experiencing an acute episode of autonomic dysreflexia?
- AAdminister an antipyretic medication給予解熱劑
- BLower the head of the bed to 0 degrees將床頭放低至0度
- CCheck the client’s bladder for distention✓ 正解檢查病人膀胱是否有脹滿
- DCheck the radial pulse for bradycardia檢查橈骨脈搏是否有心過緩
— Explanation · 中文詳解 —
自主神經反射異常（Autonomic Dysreflexia）是脊髓損傷（通常 T6 以上）病人的緊急危急狀況。其臨床特徵為突發性高血壓、心跳過慢、頭痛與臉部潮紅。最常見的誘發因子是膀胱過度充盈（尿瀦留）或糞便嵌塞。優先處置是將病人採高坐位（減少靜脈回流以降血壓），隨後移除所有刺激源，包括導尿或灌腸。
A distended bladder is the most common trigger for autonomic dysreflexia, so checking for urinary retention is a critical immediate intervention. Elevating the head of the bed also helps lower blood pressure, but removing the noxious stimulus is paramount to resolving the emergency.