— 基本照護與舒適 · MEDIUM · MCQ —
一位病人的體溫上升至 103.2°F (39.6°C)。下列哪項護理措施對立即緩解不適最有效？
A client develops a fever of 103.2°F (39.6°C). Which nursing intervention is most effective for immediate comfort?
- AEncourage the client to take a cold shower鼓勵病人洗冷水澡
- BApply cold ice packs to the axilla在腋下應用冰冷凍袋
- CRemove heavy blankets and excess clothing✓ 正解移除厚重的毯子和過多衣物
- DAdminister an antipyretic medication給予退燒藥物
— Explanation · 中文詳解 —
對於高燒病人，首要護理是移除過多的遮蓋物以促進散熱，並在給藥後監測反應。冷水澡或直接使用冰敷袋容易導致病人寒顫（shivering），寒顫會增加氧氣需求與代謝產熱，反而讓體溫上升，因此不建議作為首選。
For a client with a high fever, the priority nursing action is to remove excess coverings to promote heat dissipation and to monitor the response after administering medication. A cold shower or direct use of ice packs can easily induce shivering, which increases oxygen demand and metabolic heat production and paradoxically raises body temperature; these measures are therefore not recommended as first-line interventions.
✦ 台美臨床差異
兩地均強調移除保暖物，但美國針對發燒有更明確的退燒藥給藥 protocol。