— 生理適應 · HARD · MCQ —
一位 T4 脊髓損傷病人出現自主神經反射異常（autonomic dysreflexia）。首要護理介入為何？
A client has a spinal cord injury at the T4 level. The nurse identifies autonomic dysreflexia. What is the priority intervention?
- ALoosen any restrictive clothing鬆開任何束縛的衣物
- BAdminister an antihypertensive medication給予降血壓藥物
- CElevate the head of the bed to a sitting position✓ 正解將床頭抬高至坐姿
- DCatheterize the client immediately立即為病人導尿
— Explanation · 中文詳解 —
自主神經反射異常（Autonomic Dysreflexia）常發生於 T6 以上的脊髓損傷病人，是一種危及生命的急症。其特徵是強烈的交感神經反應，導致血壓急速飆升。首要行動是將病人坐起或抬高床頭（至少 45 度），利用重力降低腦部血壓，並緩解頭痛。隨後應儘速尋找並消除刺激源（如過脹的膀胱、緊繃的衣服）。
Elevating the head of the bed to a sitting position is the priority intervention because it utilizes gravity to lower blood pressure and alleviate symptoms like headache. This immediate action precedes identifying and removing the underlying trigger, such as a distended bladder or tight clothing.