— 生理適應 · HARD · MCQ —
一位病人被診斷為自主神經反射異常 (Autonomic dysreflexia)，下列哪項是護理師的優先措施？
A client is diagnosed with autonomic dysreflexia. What is the priority nursing action?
- APlace the client in a sitting position✓ 正解將病人置於坐姿
- BCheck the bladder for distention檢查膀胱是否有脹滿
- CAdminister an antihypertensive給予抗高血壓藥物
- DAssess for fecal impaction評估是否有糞石嵌塞
— Explanation · 中文詳解 —
自主神經反射異常（Autonomic dysreflexia）是脊髓損傷（T6 以上）的嚴重併發症，會引發危險的急性高血壓。首要措施是將病人調整為坐姿（Sitting position），利用重力將血液滯留於下肢，以迅速降低血壓並減少腦部壓力，避免中風。隨後應迅速尋找誘因，例如檢查尿管是否阻塞導致尿滯留，或是否有糞便阻塞。
The priority nursing action for autonomic dysreflexia is to place the client in a sitting position to use gravity for lowering blood pressure and reducing intracranial pressure. This immediate intervention manages the hypertensive crisis before identifying and removing the trigger, such as bladder distention or fecal impaction. Antihypertensives are considered only if positioning does not resolve the crisis.