— 照護管理 · HARD · MCQ —
護理師接班後，應優先評估下列哪位病人？
A nurse is caring for multiple clients. Which client should the nurse assess first after receiving shift report?
- AA client reporting mild discomfort after physical therapy一位報告物理治療後有輕微不適的病人
- BA client with a scheduled dressing change at 10:00 AM一位預約上午 10:00 換藥的病人
- CA client with a new onset of sudden confusion and restlessness✓ 正解一位新出現突然意識混亂和煩躁不安的病人
- DA client waiting for discharge papers with stable vitals一位生命徵象穩定且等待出院文件的病人
— Explanation · 中文詳解 —
護理師在接班後需依據 ABC（Airway, Breathing, Circulation）原則與急迫性（Urgency）評估。突然出現的意識混亂（Confusion）與躁動（Restlessness）通常是缺氧（Hypoxia）、低血糖、休克或神經系統急性惡化的早期徵兆，屬於危及生命的狀況，需立即評估與介入。
After receiving shift report, the nurse prioritizes by ABC (airway, breathing, circulation) and urgency. New-onset confusion and restlessness often signal hypoxia, hypoglycemia, shock, or acute neurological decline—life-threatening conditions that require immediate assessment and intervention.