— 照護管理 · HARD · MCQ —
護理師正在評估一位疑似闌尾炎的病人，下列何項發現需要立即的護理介入？
A nurse is assessing a client with suspected appendicitis. Which finding requires immediate nursing intervention?
- AAbdominal pain initially around the umbilicus, now localized to the right lower quadrant腹痛最初位於臍周，現在定位於右下象限
- BRebound tenderness upon palpation of the right lower quadrant觸診右下象限時出現反彈痛
- CSudden, severe, generalized abdominal pain with abdominal rigidity✓ 正解突然且嚴重的全身性腹痛伴隨腹部僵硬
- DTemperature of 101.5°F (38.6°C)體溫 101.5°F (38.6°C)
— Explanation · 中文詳解 —
疑似闌尾炎的病人若出現突發、劇烈、廣泛性腹痛並伴隨腹壁僵硬（Rigidity），這通常提示闌尾已經穿孔（Perforation），導致腹膜炎（Peritonitis）。腹膜炎是嚴重的急腹症，若不即時處理可能進展為敗血症與休克，危及生命，需立即啟動手術準備。其他選項（轉移性疼痛、反彈痛、發燒）雖為闌尾炎的典型表現，但不如穿孔危急。
In a client with suspected appendicitis, sudden, severe, generalized abdominal pain with abdominal rigidity typically indicates appendiceal perforation and resulting peritonitis. Peritonitis is a serious surgical emergency that can progress to sepsis and shock if not treated immediately; the client requires urgent surgical preparation. The other findings (migratory pain, rebound tenderness, fever) are typical of appendicitis but less acute than perforation.