— 照護管理 · HARD · MCQ —
護理師在急診進行檢傷分類，哪位病人需要立即評估？
A nurse is responsible for triaging clients in the emergency department. Which client requires immediate assessment?
- AA client with a closed wrist fracture reporting intense pain主訴劇烈疼痛的閉合性手腕骨折病人
- BA client with a minor laceration needing sutures需要縫合的輕微撕裂傷病人
- CA client with an earache and low-grade fever耳痛伴隨低燒的病人
- DA client with a suspected myocardial infarction presenting with crushing chest pain✓ 正解呈現壓榨性胸痛、疑似心肌梗塞的病人
— Explanation · 中文詳解 —
急診檢傷分類依病情危急度而定。心肌梗塞（MI）可能迅速惡化導致心跳停止，屬於高危險狀態（第一或第二優先級），需立即處理。閉鎖性骨折雖痛苦但生命徵象通常穩定。撕裂傷與中耳炎屬於非危急病患，可列入後續處理名單。
Emergency department triage is based on the severity of the client's condition. Myocardial infarction (MI) can rapidly deteriorate to cardiac arrest, representing a high-acuity state (priority level 1 or 2) requiring immediate attention. A closed fracture is painful, but vital signs are usually stable. Lacerations and otitis media are non-urgent conditions and can be placed in the follow-up queue.
✦ 台美臨床差異
台灣急診常有擁擠問題，檢傷分類系統與美國相似，但實際執行上對「急」的定義有時會受到病患流量影響。