— 生理適應 · HARD · SATA —
一位疑似腦膜炎的病人，護理師應評估哪些徵象？（選所有適合的）
A client is admitted with suspected meningitis. Which signs should the nurse assess for? (Select all that apply.)
- ANuchal rigidity✓ 正解頸部僵硬
- BPositive Kernig's sign✓ 正解Kernig 徵象陽性
- CPositive Brudzinski's sign✓ 正解Brudzinski 徵象陽性
- DPhotophobia✓ 正解畏光
- EHypotension低血壓
— Explanation · 中文詳解 —
腦膜炎（Meningitis）典型徵象包括頸部僵硬（Nuchal rigidity）、Kernig's 徵象陽性（膝蓋伸展受限）、Brudzinski's 徵象陽性（頸部彎曲導致膝蓋彎曲）以及畏光（Photophobia）。低血壓並非典型腦膜炎症狀，但在嚴重敗血症時可能出現，非診斷腦膜炎的主要指標。
Classic signs of meningitis include nuchal rigidity, positive Kernig's sign (resistance to knee extension), positive Brudzinski's sign (hip/knee flexion when neck is flexed), and photophobia. Hypotension is not a typical meningitis sign but may appear in severe sepsis; it is not a primary diagnostic indicator.