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照護管理 · MEDIUM · MCQ

護理師正在收納一位疑似中風的病人,家屬表示病人突然無法說話且臉部單側下垂。護理師應優先採取何項措施?

A nurse is admitting a client with a suspected stroke. The client's family reports the client suddenly became unable to speak and has facial drooping on one side. Which action should the nurse take FIRST?

  • APrepare for computed tomography (CT) scan
    準備進行電腦斷層掃描(CT)
  • BCheck blood glucose level✓ 正解
    測量血糖
  • CAdminister aspirin
    給予阿斯匹靈
  • DPerform a neurological assessment using the NIHSS scale
    使用NIHSS量表進行神經學評估
Explanation · 中文詳解

面對急性類中風症狀,護理師需遵循「安全優先」原則。低血糖(Hypoglycemia)的臨床表現與中風幾乎無法區分(如單側無力、口齒不清、意識模糊),被稱為「假中風」。若不先檢查血糖,可能導致病人接受錯誤的侵入性檢查或延誤糾正低血糖的時間,甚至造成腦部永久損傷。因此,快速血糖檢查是排除鑑別診斷的首要步驟。

When confronting acute stroke-like symptoms, the nurse must follow the principle of safety first. Hypoglycemia can produce a clinical presentation almost indistinguishable from stroke (such as unilateral weakness, slurred speech, and altered mental status) and is known as "pseudo-stroke." Without first checking the blood glucose, the client may undergo incorrect invasive testing or experience a delay in correction of hypoglycemia, potentially leading to permanent brain damage. A rapid blood glucose check is therefore the first step in the differential diagnosis.

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