護理師為一位疑似腦膜炎的病人進行入院評估。哪些發現支持此診斷？（選所有適合的）
A nurse is performing an admission assessment on a client with suspected meningitis. Which findings would support this diagnosis? (Select all that apply.)
- ANuchal rigidity✓ 正解頸部僵硬
- BPositive Kernig's sign✓ 正解克尼格氏徵（Kernig's sign）陽性
- CPhotophobia✓ 正解畏光
- DHyperactivity and increased appetite過度活躍和食慾增加
- ESevere headache✓ 正解劇烈頭痛
腦膜炎的典型臨床特徵源於腦膜受刺激。1. 頸部僵硬（Nuchal rigidity, A）是腦膜受累的最常見體徵。2. Kernig's sign（B）陽性是指病人平臥、大腿伸直時感疼痛，顯示脊髓膜受刺激。3. 畏光（C）與劇烈頭痛（E）是因為發炎導致對光線與壓力敏感。D 是明顯錯誤：病人通常會表現為嗜睡（Lethargy）、噁心、嘔吐與食慾不振，而非過動。早期識別這些「紅旗指標」對於減少風險潛力至關重要，因為細菌性腦膜炎若不立即給予抗生素，死亡率與後遺症發生率極高。護理師的評估是啟動腰椎穿刺等診斷流程的第一步。
Typical clinical features of meningitis result from meningeal irritation. 1. Nuchal rigidity (A) is the most common sign of meningeal involvement. 2. A positive Kernig's sign (B) refers to pain when the client lies supine with the leg extended, indicating spinal meningeal irritation. 3. Photophobia (C) and severe headache (E) result from inflammation causing sensitivity to light and pressure. D is clearly incorrect: clients typically exhibit lethargy, nausea, vomiting, and decreased appetite rather than hyperactivity. Early recognition of these 'red flag' indicators is essential to reduce risk because untreated bacterial meningitis has very high mortality and sequelae rates. The nurse's assessment is the first step in initiating diagnostic procedures such as lumbar puncture.
在美國，疑似腦膜炎會立即啟動「Droplet Precautions」（飛沫隔離）直至排除細菌性感染；台灣同樣執行隔離，但臨床護理師更強調在腰椎穿刺後的平臥照護以預防頭痛。