NurslixJournal
照護管理 · EASY · MCQ

護理師在急診進行檢傷分類,哪位病人應優先處理?

A nurse is performing triage in an emergency department. Which client should the nurse see first?

  • AA 22-year-old with a possible ankle fracture
    一位可能踝關節骨折的22歲患者
  • BA 60-year-old with a history of hypertension presenting with a mild headache
    一位有高血壓病史並出現輕微頭痛的60歲患者
  • CA 50-year-old with crushing chest pain and diaphoresis✓ 正解
    一位有壓榨性胸痛和盜汗的50歲患者
  • DA 35-year-old with a laceration on the forearm actively bleeding
    一位前臂有傷口且正在活動性出血的35歲患者
Explanation · 中文詳解

急診檢傷分類核心為 ABC 優先原則,胸痛合併盜汗為典型心肌梗塞臨床表現,屬於極高危急症,若不即時介入可能發展為心律不整或心跳停止。手臂割傷雖然出血但可先採加壓止血,腳踝骨折與頭痛均非致命性立即風險,應排在穩定生命徵象之後。

The core of emergency department triage is the ABC priority principle. Chest pain combined with diaphoresis is a classic clinical presentation of myocardial infarction and constitutes an extreme emergency; without prompt intervention, it can progress to arrhythmia or cardiac arrest. Although the forearm laceration is bleeding, hemorrhage can first be controlled with direct pressure, and ankle fracture and headache do not pose an immediate threat to life; these should be addressed after vital signs have been stabilized.

✦ 台美臨床差異

美國急診多使用 ESI 系統進行分級;台灣則採用 TTS 分級系統,兩者對於心臟急症的優先權定義高度一致。

Related · 同分類的其他題目

More from Management of Care

瀏覽全部 1,949 題 照護管理 →
Jump to another chapter