— 降低風險 · HARD · MCQ —
當病人出現自主神經反射異常（autonomic dysreflexia）時，護理師應優先採取哪項措施？
Which of the following interventions should a nurse prioritize for a client who is exhibiting symptoms of autonomic dysreflexia?
- AElevate the head of the bed to a high-Fowler's position✓ 正解將床頭抬高至高福勒氏臥位
- BLoosen any restrictive clothing鬆開任何緊縮的衣物
- CAdminister an antihypertensive medication給予抗高血壓藥物
- DCheck the bladder for distention檢查膀胱是否脹大
— Explanation · 中文詳解 —
自主神經反射異常（Autonomic dysreflexia）常見於脊髓損傷（T6 以上）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嚴重高血壓。首要措施是立即將床頭抬高（High-Fowler's），利用重力產生姿勢性低血壓，以緩解高血壓帶來的腦出血風險，隨後才處理誘因（如膀胱脹大、便秘）。
Autonomic dysreflexia is a life-threatening emergency in clients with spinal cord injuries at T6 or above, characterized by severe hypertension. The priority intervention is to elevate the head of the bed to a high-Fowler's position to promote orthostatic hypotension and reduce intracranial pressure, which takes precedence over identifying or removing the underlying stimulus.
✦ 台美臨床差異
美國臨床對於脊損病人的自主神經反射異常有明確的緊急處理程序（Protocol），護理師應具備立即辨識症狀（如劇烈頭痛、心搏過緩、發汗）的能力，並在醫師指令下迅速依程序處理誘因。