— 生理適應 · HARD · MCQ —
一位 C4 頸椎脊髓損傷 (SCI) 個案，出現哪些評估發現暗示已發展為自主神經反射異常 (autonomic dysreflexia)？
Which assessment finding in a client with a cervical spinal cord injury (SCI) at C4 suggests the development of autonomic dysreflexia?
- AFever and generalized rash發燒和全身性皮疹
- BHypotension and bradycardia低血壓和心動過緩
- CSevere hypertension and headache✓ 正解嚴重高血壓和頭痛
- DRespiratory distress and cyanosis呼吸困難和發紺
— Explanation · 中文詳解 —
自主神經反射異常是脊髓損傷（通常 T6 以上）的致命併發症。典型症狀為突發嚴重高血壓、搏動性頭痛、損傷部位以上潮紅與流汗，以及損傷部位以下皮膚蒼白與寒冷。這通常由膀胱充盈或腸道刺激引起，需立即緩解誘因。
Autonomic dysreflexia is a life-threatening complication in clients with spinal cord injuries at T6 or above, characterized by sudden severe hypertension and pounding headache. These symptoms result from an unregulated sympathetic nervous system response to noxious stimuli below the level of injury.
✦ 台美臨床差異
此為美國 NCLEX 必考題，兩地處理原則一致，皆首重「立即坐起」以透過姿勢性低血壓機制降低血壓。