— 照護管理 · MEDIUM · SATA —
一位護理師正在管理患有多種疾病的病人。哪位病人需要最立即的評估？（選所有適合的）
A nurse is managing care for clients with various conditions. Which client requires the MOST immediate assessment? (Select all that apply.)
- AA client with type 1 diabetes reporting blood glucose of 400 mg/dL.✓ 正解一位第一型糖尿病病人報告血糖為 400 mg/dL。
- BA client post-abdominal surgery reporting mild incisional pain.一位腹部手術後病人報告切口輕微疼痛。
- CA client with a history of asthma experiencing mild wheezing.一位有氣喘病史的病人出現輕微喘鳴。
- DA client with a urinary tract infection reporting burning on urination.一位泌尿道感染病人報告排尿時有灼熱感。
- EA client with a history of stroke reporting sudden slurred speech.✓ 正解一位有中風病史的病人報告突然出現語謔。
— Explanation · 中文詳解 —
選項 A（血糖 400 mg/dL）提示嚴重高血糖，可能發展為糖尿病酮酸中毒（DKA）或高滲透壓性昏迷（HHS），需立即處理。選項 E（突發言語不清）是中風的警訊，可能表示再次中風，需立即評估。選項 B、C、D 雖需處理，但相對不緊急。
Option A (blood glucose of 400 mg/dL) signals severe hyperglycemia that may progress to diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic syndrome (HHS), and it requires immediate management. Option E (sudden slurred speech) is a warning sign of stroke and may indicate a recurrent stroke, also requiring immediate assessment. Options B, C, and D require care but are comparatively less urgent.
✦ 台美臨床差異
兩地對緊急狀況判斷標準一致。美國的急診分級系統更為明確；台灣臨床現場，護理師需依經驗快速判斷，並與醫師協調優先順序。