一位護理師正在管理一位新診斷為中風的病人。哪項評估發現需要立即的護理介入？
A nurse is managing care for a client with a new diagnosis of stroke. Which assessment finding requires immediate nursing intervention?
- AArm weakness on one side.單側手臂無力
- BSudden severe headache with altered mental status.✓ 正解突發性劇烈頭痛伴隨意識狀態改變
- CFacial droop on one side.單側臉部下垂
- DSlurred speech.語音含糊不清
中風後的評估必須遵循危急程度分級。雖然臉部下垂、言語不清和肢體無力是中風的典型神經學症狀，但它們屬於病情進展的一部分。然而，突然劇烈頭痛合併意識狀態改變（Altered Mental Status）是顱內出血（Intracranial Hemorrhage）或腦水腫加劇的強烈徵兆，可能導致腦疝（Brain Herniation）甚至死亡，屬於生命危險的緊急情況，必須立即通知醫師並啟動緊急醫療應變程序。
Post-stroke assessment must follow criticality-based prioritization. Although facial droop, slurred speech, and limb weakness are typical neurological symptoms of stroke, they are part of the disease progression. However, a sudden severe headache combined with altered mental status is a strong indicator of intracranial hemorrhage or worsening cerebral edema, which may lead to brain herniation and even death. This constitutes a life-threatening emergency that requires immediate physician notification and activation of emergency medical response procedures.
美國醫院針對中風常啟動「Stroke Code」機制，由跨領域團隊（Neurology, ER, ICU）立即介入；台灣亦有類似的中風小組（Stroke Team）運作模式。