— 基本照護與舒適 · MEDIUM · SATA —
護理師照護術後病人，哪些跡象顯示病人正經歷疼痛？（選所有適合的）
A nurse is caring for a patient who is post-operative. Which of the following signs indicate that the client is experiencing pain? (Select all that apply.)
- AIncreased heart rate✓ 正解心跳速率增加
- BGuarding the incision site✓ 正解保護切口部位
- CDecreased respiratory rate呼吸速率減慢
- DFacial grimacing✓ 正解面部扭曲
- ERestlessness or agitation✓ 正解躁動不安或煩躁
— Explanation · 中文詳解 —
疼痛會導致交感神經興奮，進而引起心跳加快、血壓上升。在行為觀察上，病人常表現出保護傷口的動作（Guarding）、痛苦面容（Grimacing）及焦躁不安（Agitation）。呼吸通常會變快而非變慢，因此C選項是錯誤的。
Pain activates the sympathetic nervous system, leading to an increased heart rate and elevated blood pressure. Behavioral observations frequently include guarding of the wound, facial grimacing, and agitation. The respiratory rate generally increases rather than decreases, which is why option C is incorrect.
✦ 台美臨床差異
美國護理重視疼痛作為「第五生命徵象」，台灣臨床對於術後疼痛管理依賴病患口述，非語言指標觀察同樣重要。