— 基本照護與舒適 · EASY · MCQ —
一位有心衰竭病史的病人正欲前往廁所，突然主訴頭暈。護理師應採取的優先措施為何？
A nurse is assisting a client with a history of heart failure to the bathroom. The client reports sudden lightheadedness. What is the nurse's priority action?
- AAssist the client to sit or lie down immediately✓ 正解立即協助病人坐下或躺下
- BCall for help to transfer the client呼叫協助以轉移病人
- CContinue to the bathroom but walk slowly繼續前往廁所但放慢腳步
- DCheck the client's blood pressure測量病人的血壓
— Explanation · 中文詳解 —
對於有心衰竭（Heart Failure）病史的病人，活動中突然頭暈（lightheadedness）可能是姿勢性低血壓、心律不整或心輸出量不足的徵兆。在護理優先順序（Prioritization）中，病人安全永遠是第一考量。當病人主訴頭暈時，跌倒風險極高，護理師應立即協助病人坐下或躺下，以降低重心並預防跌倒造成二次傷害。
For a client with heart failure, sudden lightheadedness during activity may indicate orthostatic hypotension, dysrhythmia, or decreased cardiac output. Safety is the priority, so the nurse should immediately assist the client to sit or lie down to lower the center of gravity and prevent a fall.