— 基本照護與舒適 · MEDIUM · MCQ —
病人在服用口服止痛藥 30 分鐘後仍反映疼痛劇烈，護理師優先評估重點為何？
A client complains of significant pain 30 minutes after receiving oral analgesics. What is the nurse's priority assessment?
- AVital signs including blood pressure and heart rate包含血壓和心跳速率的生命徵象
- BThe time of the next medication dose下一次給藥的時間
- CThe client's ability to sleep or rest病人入睡或休息的能力
- DThe client's pain intensity and character using a standardized scale✓ 正解使用標準化量表評估病人的疼痛強度與性質
— Explanation · 中文詳解 —
疼痛是主觀的，病人對藥物反應的評估必須基於客觀的測量工具。當給藥 30 分鐘後（通常是口服藥物發揮藥效的時間）疼痛未減輕，護理師的第一優先行動是重新評估疼痛的強度、性質、部位與持續時間。這不僅是為了判斷藥物成效，更是為了排除潛在的急性病變或併發症。臨床思路遵循護理過程（Nursing Process）的評估（Assessment）階段，必須在採取進一步行動前獲得明確的臨床數據。
Pain is subjective, and assessment of medication response must use a standardized tool. When pain persists 30 minutes after an oral analgesic (typical onset time), the priority is to reassess intensity, character, location, and duration. This data determines whether the medication is effective or whether another condition (such as a complication) must be ruled out, following the nursing process.