— 基本照護與舒適 · HARD · MCQ —
一位病人表示術後感到劇烈疼痛，哪項評估結果顯示交感神經系統對疼痛的反應？
A client complains of significant pain after surgery. Which assessment finding indicates a sympathetic nervous system response to pain?
- AIncreased skin temperature皮膚溫度升高
- BBradycardia心跳過緩
- CDilated pupils✓ 正解瞳孔擴大
- DDecreased blood pressure血壓下降
— Explanation · 中文詳解 —
急性疼痛會活化交感神經系統，引發「戰鬥或逃跑」反應。其生理特徵包括：瞳孔放大（便於觀察環境）、心搏過速、血壓升高及周邊血管收縮（導致皮膚濕冷）。低血壓、心跳過慢或溫暖皮膚通常與副交感神經或休克晚期有關。
Acute pain activates the sympathetic nervous system, triggering a "fight or flight" response. Physiologic features include pupillary dilation (to enhance environmental awareness), tachycardia, elevated blood pressure, and peripheral vasoconstriction (producing cool, clammy skin). Hypotension, bradycardia, and warm skin generally reflect parasympathetic activity or late-stage shock.
✦ 台美臨床差異
台美護理教育均強調疼痛的生理評估指標，但美國更強調將疼痛視為第五生命徵象，給藥執行上護理師自主權限較高。