— 照護管理 · HARD · MCQ —
急診護理師進行檢傷分類，哪位病人應優先處理？
A nurse is triaging patients in the emergency department. Which patient should be seen first?
- AA 22-year-old with abdominal pain and a positive pregnancy test一位22歲、有腹痛且驗孕陽性的病人
- BA 10-year-old with a possible fractured arm and localized pain一位10歲、可能有手臂骨折並伴隨局部疼痛的病人
- CA 45-year-old with a history of hypertension complaining of severe headache一位有高血壓病史並抱怨嚴重頭痛的四十五歲病人
- DA 60-year-old with shortness of breath and a history of heart failure✓ 正解一位有心臟衰竭病史並出現呼吸困難的六十歲病人
— Explanation · 中文詳解 —
檢傷分類依據生命徵象與危急度，呼吸困難（Shortness of breath）在心衰竭病人身上可能代表急性肺水腫，屬呼吸循環緊急狀況（ABC）。A 為骨科問題，C 為高血壓危象但非立即性呼吸衰竭，A 為婦科問題需排除子宮外孕，但相較於呼吸窘迫，D 的優先級最高。
Triage prioritizes life-threatening airway, breathing, and circulation problems first. Shortness of breath in a client with heart failure may indicate acute pulmonary edema—a respiratory and circulatory emergency. The fracture is non-emergent, the headache with hypertension needs evaluation but is not immediately airway-threatening, and abdominal pain with positive pregnancy test (concern for ectopic) requires evaluation but the heart-failure client takes priority.
✦ 台美臨床差異
美台檢傷系統（如 ESI）皆將呼吸困難列為最高優先層級，臨床判斷邏輯相同。