— 照護管理 · HARD · MCQ —
內外科病房護理師需評估四位病人，哪一位應優先處理？
A nurse on a medical-surgical unit is tasked with prioritizing care for four clients. Which client should the nurse see first?
- AA client with a new onset of sudden confusion and restlessness✓ 正解新發急性意識混亂和煩躁不安的病人
- BA client scheduled for discharge with a pending pharmacy medication review預約出院且藥局藥物審查待定的病人
- CA client with type 1 diabetes reporting a blood glucose of 140 mg/dL第一型糖尿病病人報告血糖為 140 mg/dL
- DA client 2 days post-appendectomy complaining of moderate incisional pain闌尾切除術後兩天抱怨切口中度疼痛的病人
— Explanation · 中文詳解 —
根據 ABC 原則與急迫性（Priority Setting），突然出現的意識混亂與躁動（New onset of confusion）常是低血氧、敗血症或腦部病變的警訊，具有潛在生命威脅，必須優先評估，排除神經學異常或急性呼吸衰竭。
According to the ABC principle and priority setting, new-onset confusion and restlessness are often warning signs of hypoxia, sepsis, or cerebral pathology, with potential life-threatening implications, and must be assessed first to rule out neurologic abnormalities or acute respiratory failure.
✦ 台美臨床差異
優先級排序在台美臨床中均強調「急、重、危」優先，此為護理師核心職能。