— 生理適應 · HARD · SATA —
病人出現自主神經反射異常症狀。護理師應執行哪些護理措施？（選所有適合的）
A client is experiencing symptoms of autonomic dysreflexia. Which nursing interventions should be implemented? (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 for urinary retention or kinked catheter✓ 正解檢查是否有尿液滯留或導尿管扭結
- CAdminister an anti-hypertensive medication as ordered✓ 正解依醫囑給予抗高血壓藥物
- DAssess for fecal impaction✓ 正解評估是否有糞便嵌塞
- EApply a cold pack to the forehead在前額敷上冰袋
— Explanation · 中文詳解 —
自主神經反射異常是脊髓損傷 T6 以上的醫療緊急狀況。首要步驟是將病人坐起（高半坐臥）以降低腦部血壓，接著尋找刺激源（最常見為尿滯留、宿便）。移除刺激物後給予降血壓藥。冰敷額頭非標準處置，且該病患血壓波動劇烈，任何不必要的刺激皆需避免。
Autonomic dysreflexia is a medical emergency requiring immediate intervention to lower blood pressure and remove the triggering stimulus. The nurse should place the client in a high-Fowler's position to reduce cerebral blood pressure and assess for common causes such as urinary retention or fecal impaction. If the stimulus is not resolved, administering prescribed antihypertensive medication is necessary to prevent severe complications like stroke.
✦ 台美臨床差異
自主神經反射異常在脊損傷病房為護理重點，兩地護理標準皆為發現後立即坐起與排查刺激源。