— 生理適應 · HARD · MCQ —
護理師照顧一位疑似脊髓損傷的病人，應避免使用哪種評估技術？
A nurse is caring for a client with a potential spinal cord injury. Which assessment technique should the nurse avoid?
- ARespiratory rate monitoring監測呼吸頻率
- BDeep tendon reflex testing測試深層肌腱反射
- CFlexing the neck to check for rigidity✓ 正解彎曲頸部以檢查是否有僵硬現象
- DNeurological examination神經學檢查
— Explanation · 中文詳解 —
脊髓損傷（Spinal cord injury）的評估與處置必須極度謹慎。在未透過影像學檢查排除脊椎骨折或不穩定性之前，任何頸部的屈曲、伸展或扭轉動作，都可能導致受損的脊髓再次受到剪力損傷，造成永久性的癱瘓。因此，護理師需維持頸椎的中立位（Neutral alignment），並嚴格禁止任何會改變脊椎排列的評估動作。
Before imaging confirms spinal stability, any neck flexion, extension, or rotation must be avoided to prevent shear forces that could worsen spinal cord damage. The nurse should maintain neutral cervical alignment and strictly prohibit assessments that alter spinal positioning.