— 降低風險 · MEDIUM · MCQ —
護理師照護一位剛接受甲狀腺切除術的病人。下列哪項評估結果需要立即介入？
A nurse is caring for a client who has just returned from a thyroidectomy. Which assessment finding requires immediate intervention?
- ADrainage of 20 mL of serosanguineous fluid in the JP drainJP 引流管中有 20 mL 的血清血性引流液
- BHeart rate of 88 beats per minute心率每分鐘 88 次
- CMild hoarseness when speaking說話時輕微聲音沙啞
- DPositive Trousseau's sign✓ 正解Trousseau 徵象陽性
— Explanation · 中文詳解 —
甲狀腺切除術後，副甲狀腺若受損會導致血鈣降低。Trousseau 徵象陽性是低血鈣的指標，可能導致喉頭痙攣及呼吸道阻塞，屬於致命性併發症，需優先處理。輕微聲音沙啞可能與插管有關，JP 引流量在正常範圍內，心跳則屬穩定數值。
After thyroidectomy, damage to the parathyroid glands can cause hypocalcemia. A positive Trousseau sign is a marker of hypocalcemia and may herald laryngospasm and airway obstruction — a potentially fatal complication that must be addressed first. Mild voice hoarseness may be related to intubation, the JP drain output is within the normal range, and the heart rate represents a stable value.
✦ 台美臨床差異
台灣醫院通常會備妥鈣劑在床邊，護理師發現徵象可立即依醫囑給予；美國則更強調整體神經學監測。