— 照護管理 · HARD · MCQ —
護理師照護一位懷疑中風的病人，下列哪項評估為優先？
A nurse is caring for a client with a suspected stroke. Which assessment is the priority?
- AAssess blood pressure and heart rate測量血壓和心率
- BDetermine the time of symptom onset✓ 正解確定症狀發作時間
- CPerform a swallowing screen進行吞嚥篩檢
- DCheck for facial droop and arm drift檢查是否有臉頰下垂和手臂無力下垂
— Explanation · 中文詳解 —
針對懷疑中風的病人，了解「症狀發作時間（Last known well）」是醫療處置的首要關鍵，因為這決定了病人是否符合血栓溶解劑（tPA）的給藥時間窗口（通常為 3-4.5 小時）。錯過時間則無法施行溶栓治療，對預後影響重大。
For a patient with suspected stroke, determining the time of symptom onset ("last known well") is the most critical factor for medical management, because it determines whether the patient is eligible for thrombolytic therapy (tPA), typically within a 3-4.5 hour window. Missing this window precludes thrombolysis and has major implications for prognosis.
✦ 台美臨床差異
美國 Stroke Center 有極嚴格的 Door-to-Needle 指標；台灣醫學中心同樣執行該流程，但在院前轉診與分流效率上略有不同。