— 生理適應 · HARD · SATA —
病人發生自主神經反射異常（Autonomic Dysreflexia）時，哪些處置是適當的？（選所有適合的）
Which of the following interventions are appropriate for a client experiencing an autonomic dysreflexia crisis? (Select all that apply.)
- APlace the client in a high-Fowler's position✓ 正解將病人置於高福勒氏臥位
- BCheck the indwelling urinary catheter for kinks or blockage✓ 正解檢查導尿管是否有扭曲或阻塞
- CAdminister an antihypertensive medication as ordered✓ 正解依醫囑給予降血壓藥物
- DPerform a digital rectal exam to check for fecal impaction✓ 正解進行數位肛門檢查以確認是否有糞便嵌塞
- EApply a tight abdominal binder to decrease blood pressure使用緊束的腹部束帶以降低血壓
— Explanation · 中文詳解 —
自主神經反射異常是脊髓損傷（T6 以上）的危急併發症。首要目標為降低血壓並移除刺激源。採半坐臥位可減少靜脈回流以降低血壓。接著需檢查膀胱引流管（最常見誘因）及直腸（糞便嵌塞）。給予降血壓藥是為了避免高血壓腦病變。選項 E 錯誤，腹帶壓迫會增加腹壓，反而可能加重症狀。
Autonomic dysreflexia requires immediate positioning in high-Fowler's to lower blood pressure and identification of triggers like urinary retention or fecal impaction. Antihypertensives may be administered to prevent stroke, while tight abdominal binders should be avoided as they can worsen symptoms.
✦ 台美臨床差異
美國護理訓練中對 AD 的緊急 Protocol 非常嚴謹且強調獨立反應；台灣臨床多在復健科較常見，護理師的熟悉度視單位屬性而異。