— 降低風險 · HARD · MCQ —
護理師照護一位蜘蛛膜下腔出血（SAH）的病人，哪項護理行動為首要？
A nurse is caring for a client with a continuous subarachnoid hemorrhage (SAH). Which nursing action is priority?
- APerforming frequent neurological assessments✓ 正解進行頻繁的神經學評估
- BAllowing the client to move freely in bed允許病人在床上自由活動
- CTurning the client every 2 hours每2小時協助病人翻身
- DEncouraging a high-fiber diet鼓勵高纖維飲食
— Explanation · 中文詳解 —
蜘蛛膜下腔出血（SAH）病人的首要風險在於再出血（rebleeding）與腦血管痙攣（vasospasm）。頻繁的神經學評估是偵測顱內壓變化或腦灌流不足的黃金標準（Gold Standard）。透過 Glasgow Coma Scale（GCS）、瞳孔反應及肢體活動度的連續性監測，護理師能及早發現微小的神經功能改變，從而預防嚴重的不可逆腦損傷。
The primary risks in SAH are rebleeding and cerebral vasospasm. Frequent neurological assessment is the gold standard for detecting changes in intracranial pressure or cerebral perfusion. Continuous monitoring with the Glasgow Coma Scale (GCS), pupillary response, and motor activity allows early detection of subtle neurological changes, preventing severe irreversible brain damage.