病人出現自主神經反射異常徵象，護理師應立即執行的優先動作為何？
A client presents with signs of autonomic dysreflexia. Which nursing action is the most immediate priority?
- AAssess bowel sounds評估腸鳴音
- BElevate the head of the bed✓ 正解抬高床頭
- CCheck for bladder distention檢查膀胱脹滿情況
- DAdminister antihypertensive medication給予降血壓藥物
自主神經反射異常（Autonomic Dysreflexia, AD）是脊髓損傷（T6 或以上）後的致命性併發症，其特徵為陣發性高血壓、心跳過緩及頭痛。當刺激源（如膀胱脹、宿便）引發交感神經劇烈反射，卻因脊髓損傷阻斷了副交感神經的調節，導致血壓急速飆升，甚至引發腦出血。護理師應遵循「優先順序（Priority）」原則，首要動作是將床頭抬高（至少 45-90 度），利用重力幫助血液淤積於下肢，以迅速降低顱內壓及血壓。之後才進行查找誘因（膀胱、腸道、皮膚）及給予醫囑藥物。
Elevating the head of the bed is the immediate priority to reduce blood pressure and intracranial pressure through gravity. Autonomic dysreflexia is a medical emergency often triggered by noxious stimuli such as bladder distention or fecal impaction. While identifying and removing the trigger is essential, positioning the patient upright provides the fastest initial intervention to prevent complications like stroke.
在美國臨床環境中，AD 的處理流程極為標準化，考場上特別強調「先處理病人姿勢（Positioning）」再尋找誘因。台灣臨床單位雖也遵循此原則，但部分基層單位可能習慣先檢查導尿管是否阻塞，NCLEX 考試需嚴格遵守先生命安全、後病因查找的優先級。