— 基本照護與舒適 · MEDIUM · MCQ —
病人已臥床 5 天。下列哪項評估發現需要護理師立即介入？
A client has been on bed rest for 5 days. Which assessment finding requires immediate nursing intervention?
- AMuscle weakness when attempting to stand嘗試站立時肌肉無力
- BComplaints of localized calf pain and swelling✓ 正解主訴小腿局部疼痛和腫脹
- CDry, scaly skin on the lower extremities下肢皮膚乾燥脫屑
- DDecreased bowel sounds in all four quadrants四個象限腸鳴音減弱
— Explanation · 中文詳解 —
長期臥床病人（Bed rest）因血液滯留（Stasis）、血管壁損傷及血液高凝狀態，極易形成深層靜脈栓塞（DVT）。若懷疑 DVT（如單側小腿腫脹、疼痛、發紅），必須優先處理以預防血栓脫落引發肺栓塞（PE），後者為致死性併發症，符合 ABC（Airway, Breathing, Circulation）的循環優先級。
Prolonged bed rest causes venous stasis, vessel wall injury, and hypercoagulability, predisposing to DVT. Suspected DVT (unilateral calf swelling, pain, redness) requires priority action to prevent fatal PE, in line with ABC (circulation) priority.