一位疑似脊髓損傷的病人，下列哪項行動對於預防二次傷害最為優先？
A nurse is caring for a client with a suspected spinal cord injury. Which action is the priority to prevent further injury?
- ACheck for capillary refill檢查毛細血管再充盈時間
- BEncourage the client to move their legs鼓勵病患移動雙腿
- CImmobilize the head and neck immediately✓ 正解立即固定頭部和頸部
- DKeep the client in a sitting position讓病患保持坐姿
核心概念：脊髓損傷（Spinal Cord Injury, SCI）的急性期護理。 為何正確答案對： B. 脊髓損傷急性期最關鍵的目標是預防二次損傷（Secondary Injury）。一旦懷疑有脊髓損傷，必須立即對頭部和頸部進行固定（Immobilize the head and neck），通常使用頸圈（Cervical collar）和長背板（Spinal backboard），以防止脊椎節段因移動而進一步錯位、壓迫脊髓，造成永久性神經功能喪失（如癱瘓）。 為何其他選項錯： D. 保持坐姿（Keep the client in a sitting position）可能加劇脊椎不穩定，增加損傷風險，除非有特殊情況且在專業評估下進行。 B. 鼓勵病人移動腿部（Encourage the client to move their legs）在急性期是危險的，可能導致脊髓進一步損傷。應待脊椎穩定後，在評估下才開始復健。 A. 檢查毛細血管再充盈時間（Check for capillary refill）是評估周邊灌注的指標，雖然重要，但相較於立即固定脊椎以防止進一步的神經損傷，其優先級較低。
The priority action for a client with a suspected spinal cord injury is to immobilize the head and neck immediately to prevent secondary injury and permanent neurological damage. Movement, including encouraging leg motion or sitting up, should be avoided until spinal stability is confirmed, as these actions can worsen spinal misalignment.