# 一位高位胸椎脊髓損傷的個案突然主訴劇烈頭痛。護理師觀察到臉部潮紅及血壓顯著升高。護理師應首先採取哪項行動？ > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=497754&lang=zh-tw > language: zh-TW > subject: Medical Emergencies > category: PA ## 題目 一位高位胸椎脊髓損傷的個案突然主訴劇烈頭痛。護理師觀察到臉部潮紅及血壓顯著升高。護理師應首先採取哪項行動？ ## 選項 1. 讓個案坐直，鬆開緊身物品，並評估導尿管 **✔ 正確答案** 2. 讓個案平躺，抬高雙腿，並使用溫毯以支持血壓 3. 立即開始進行數位直腸刺激，同時讓個案保持仰臥 4. 提供口服液體，調暗室內燈光，稍後再重複測量血壓 **正確答案: 1** ## 解析 這些發現顯示自律神經反射異常。讓個案坐直以降低腦壓，鬆開緊身物品，監測血壓，並快速尋找誘發因素，從膀胱脹滿或導尿管阻塞開始。 ## 深入解析 快速解答 讓個案坐直，鬆開緊身物品，並檢查導尿管。這些行動可開始降低危險的血壓，同時處理最常見的誘發因素。 為什麼這是正確的 高位脊髓損傷以下的傷害性刺激可產生不受控制的交感神經血管收縮和嚴重高血壓。坐直姿勢利用重力降低壓力，而膀胱評估則針對常見且可快速矯正的原因。 簡單比喻或心智圖像 自律神經反射異常就像阻塞控制線下方的壓力激增。坐直可打開壓力釋放路徑，同時護理師尋找阻塞處；此比喻不取代血壓監測或必要時的緊急用藥。 記憶掛鉤 高位脊髓損傷加上突發頭痛和高血壓，表示坐直、鬆開，並先檢查膀胱。 NCLEX 決策規則 對於疑似自律神經反射異常，立即採取坐直姿勢，移除壓迫，頻繁監測，並從泌尿系統開始檢查誘發因素。若血壓仍處於危險高值，則升級並給予醫囑的速效降血壓治療。 為什麼其他選項是錯的 平躺和抬高雙腿可能使高血壓惡化。直腸刺激可能加劇發作，且應在膀胱評估之後進行，而液體和延遲再評估無法處理危及生命的壓力激增。參考文獻 - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]Clinical Practice Guideline: Bladder Management for Adults with Spinal Cord InjuryConsortium for Spinal Cord Medicine ## 相同主題題目 - [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=zh-tw) - [A 68-year-old client with COPD is admitted with shortness of breath and SpO2 86% on room a…](https://mymerci.kr/pages/nclex_q.php?qn_id=362940&lang=zh-tw) - [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=zh-tw) - [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=zh-tw) - [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=zh-tw) - [A nurse is caring for a client prescribed Digoxin. Which nursing action is most appropriat…](https://mymerci.kr/pages/nclex_q.php?qn_id=374883&lang=zh-tw) - [A nurse is caring for a client prescribed Warfarin. Which nursing action is most appropria…](https://mymerci.kr/pages/nclex_q.php?qn_id=374884&lang=zh-tw) - [A nurse is caring for a client prescribed Heparin. Which nursing action is most appropriat…](https://mymerci.kr/pages/nclex_q.php?qn_id=374893&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=497754&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=497754&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=497754&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=497754&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=497754&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_