— 基本照護與舒適 · MEDIUM · MCQ —
病人因腳踝扭傷正在接受冰敷治療。哪項發現應立即回報？
A client is receiving cold therapy for a sprained ankle. Which finding should the nurse report immediately?
- AThe client reports a numbing sensation.客戶報告有麻木感
- BSkin is cool to the touch.皮膚觸感冰冷
- CSkin appears mottled or bluish.✓ 正解皮膚呈現斑駁或發紺
- DThe client states the ice pack feels heavy.客戶表示冰袋感覺沉重
— Explanation · 中文詳解 —
冰敷的常見反應包括皮膚冰涼與麻木感。然而，若出現大理石樣斑紋（Mottled）或發紺（Bluish），表示血液循環受阻或組織發生凍傷，應立即停止冰敷並通報醫師。每次冰敷不應超過 20 分鐘以防反跳性血管擴張。
Common responses to cold therapy include cool skin and numbness. However, if mottling or bluish discoloration appears, this indicates impaired circulation or frostbite, and the cold application must be stopped immediately and the physician notified. Each application of cold should not exceed 20 minutes to prevent rebound vasodilation.
✦ 台美臨床差異
美國臨床常用 RICE 原則（Rest, Ice, Compression, Elevation）；台灣亦同，但 NCLEX 更考驗對反跳效應（Rebound effect）的理解。