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生理適應 · MEDIUM · SATA

甲狀腺切除術後病患,護理師應優先評估下列哪些項目?(選所有適合的)

Which assessment findings should the nurse prioritize in a client post-thyroidectomy? (Select all that apply.)

  • APresence of stridor or high-pitched sound on inhalation✓ 正解
    是否存在喘鳴音或吸入時的高調聲
  • BSerum calcium level trends✓ 正解
    血清鈣濃度的變化趨勢
  • CInability to speak or voice changes✓ 正解
    無法說話或聲音改變
  • DDressing saturation with bright red blood✓ 正解
    敷料被鮮紅色血液浸濕的程度
  • EAbility to swallow small sips of water
    吞嚥少量水的能力
Explanation · 中文詳解

甲狀腺切除術後三大風險:氣管壓迫(喉頭水腫)、副甲狀腺損傷(低血鈣)、喉返神經損傷(嗓音改變)以及出血。A 指示呼吸道梗阻,B 指示抽搐風險,C 指示神經受損,D 指示術後出血。E 選項雖然重要,但在術後早期通常維持禁食或依醫囑,非首要生命徵象評估。

The three major risks after thyroidectomy are tracheal compression (laryngeal edema), parathyroid injury (hypocalcemia), and recurrent laryngeal nerve injury (voice changes), as well as hemorrhage. Option A indicates airway obstruction, Option B suggests risk of tetany, Option C suggests neurological injury, and Option D indicates post-operative bleeding. Although Option E is important, the client is usually NPO or follows physician orders in the early post-operative period, so it is not the priority vital-sign assessment.

✦ 台美臨床差異

美國護理師在術後評估項目更細緻,包含神經學功能的細微變化;台灣醫院則多依據標準化術後護理常規。

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